Community First Choice Maryland Department of Health and Mental Hygiene

Community First Choice CFC Overview Eligibility CFC Waiver Enrollment Process

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.

Old Service Structure 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 18-64 with disabilities Nursing Facility Level of Care standard Waiver for Older Adults (WOA) Target group aged 50 and over

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

Former Service Structure   MAPC LAH WOA 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

New Service Structure MAPC CFC Waiver Personal Assistance Services   MAPC CFC Waiver Personal Assistance Services Case Management/Supports Planning Nurse Monitoring Personal Emergency Back-up Systems Transition Services Consumer Training Home Delivered Meals1 Assistive Technology1 Accessibility Adaptations1 Environmental Assessments Medical Day Care Nutritionist/Dietician Family Training Behavioral Consultation Assisted Living Senior Center Plus Items that sub *CFC Services will be 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

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

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

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 1st More people in the community will have access to waiver-like services

CFC and Waiver Eligibility

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

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)

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

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

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

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. Citation: 73 Fed. reg. 18,676, 18,685-86 (2008)

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

CFC or Waiver? If a nursing facility resident has Long Term Care MA, they may not qualify for Community MA because the income qualifications are not the same The waiver has a higher income threshold Applicants may want to access the waiver even if they qualify for CFC, as the wavier offers additional services Consumers qualify for CFC in the community, and can apply for it from a NF regardless of their length of stay The waiver can be accessed only if the consumer has been in a NF at least 30 days with LTC MA, or from the registry if in the community Waiver participants have access to all services provided on the state plan

Enrollment in CFC from Nursing Facility Options Counselor refers to LHD for assessment* and provides Supports Planning selection packet to applicant** Contact is made with Supports Planning provider Applicant has community MA Applicant in Nursing Facility receives options counseling No community MA Options Counselor helps complete MA application. 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 DEWS Wavier Application Assistance Applicant in Nursing Facility receives options counseling Has Long Term Care MA LHD for assessment Provides Supports Planning selection packet to applicant Has Community MA Apply for CFC Insert block for transition planning Supports Planner meets with participant at least once every 90 days (can be waived by participant) Contact 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 *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 in CFC from the Community Contact DHMH Community MA status verified by DHMH Has Community MA Add to LTSS Applicant in Community Referral to LHD for assessment* Applicant contacts MAP site, referred to DHMH No Community MA Mail out Supports Planning selection packet** Refer to Local DSS 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

Enrollment into Waiver from the Community Only individuals who receive an invitation to apply from the waiver registry can apply to the waiver from the community The waiver programs reached their budgetary caps in 2003 A registry of people interested in applying was created As slots become available, invitations to apply are sent to the next group of people on the registry There are currently nearly 20,000 people on the registry People who have community MA eligibility can apply for CFC without waiting on the registry If a person needs the higher income threshold of the waiver program, they must wait on the registry and are not eligible for services CFC is not a waiver

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

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

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

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

Budget

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

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

Budgets by Group RUG Grouper Description Budget Group 1 PA1   RUG Grouper Description Budget Group 1 PA1 Physical Function – Low ADL $8,336 BA1 Behavioral – Low ADL CA1 Clin. Complex – Low ADL IA1 Cognitive Impairment – Low ADL PA2 Physical Function – Low ADL, Low to High IADL RA1 Rehabilitation - Low ADL Group 2 BA2 Behavioral – Low ADL, High IADL $16,167 CA2 Clin. Complex – Low ADL, High IADL IA2 Cognitive Impairment – Low ADL, Low to High IADL PB0 Physical Function – Low to Medium ADL Group 3 CB0 Clin. Complex – Low to Medium ADL $22,504 RA2 Rehabilitation Low – Low ADL, High IADL PC0 Physical Function – Medium to High ADL SSA Special Care – Low to High ADL IB0 Cognitive Impairment – Medium ADL BB0 Behavioral – Medium ADL Group 4 PD0 Physical Function – High ADL $30,314 CC0 Clin. Complex – High ADL Group 5 SE1 Extensive Services 1 – Medium to High ADL $34,545 RB0 Rehabilitation High – High ADL SSB Special Care – Very High ADL Group 6 SE2 Extensive Services 2 – Medium to High ADL $43,558 Group 7 SE3 Extensive Services 3 – Medium to High ADL $76,360   RUG Grouper Description Budget Group 1 PA1 Physical Function – Low ADL $8,336 BA1 Behavioral – Low ADL CA1 Clin. Complex – Low ADL IA1 Cognitive Impairment – Low ADL PA2 Physical Function – Low ADL, Low to High IADL RA1 Rehabilitation - Low ADL Group 2 BA2 Behavioral – Low ADL, High IADL $16,167 CA2 Clin. Complex – Low ADL, High IADL IA2 Cognitive Impairment – Low ADL, Low to High IADL PB0 Physical Function – Low to Medium ADL Group 3 CB0 Clin. Complex – Low to Medium ADL $22,504 RA2 Rehabilitation Low – Low ADL, High IADL PC0 Physical Function – Medium to High ADL SSA Special Care – Low to High ADL IB0 Cognitive Impairment – Medium ADL BB0 Behavioral – Medium ADL Group 4 PD0 Physical Function – High ADL $30,314 CC0 Clin. Complex – High ADL Group 5 SE1 Extensive Services 1 – Medium to High ADL $34,545 RB0 Rehabilitation High – High ADL SSB Special Care – Very High ADL Group 6 SE2 Extensive Services 2 – Medium to High ADL $43,558 Group 7 SE3 Extensive Services 3 – Medium to High ADL $76,360

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

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

Rates for Personal Assistance Participants choosing to self-direct, may elect to pay their provider from the minimum current rate ($10.22) to the maximum current rate ($14.27). For participants choosing not to self-direct, the number of personal assistance hours will be calculated based on the budget and the standard independent and/or agency rate The proposed standard independent and agency rate is the weighted average of the current FY14 rates. Independent weighted average rate: $12.27 Agency weighted average rate: $16.08 This range would be adjusted each year in the event of rate increases approved during the state budget process.

Example--Participants receiving personal assistance services 7 days a week   Annual Budget Daily Budget Hours at Min independent rate ($10.22) Hours at Max independent rate ($14.27) Hours at weighted rate ($12.27) Hours at weighted agency rate ($16.08) Group 1 $ 8,336 $22.84 2.2 1.6 1.9 1.4 Group 2 $ 16,167 $44.29 4.3 3.1 3.6 2.8 Group 3 $ 22,504 $61.65 6.0 5.0 3.8 Group 4 $ 30,314 $83.05 8.1 5.8 6.8 5.2 Group 5 $ 34,545 $94.64 9.3 6.6 7.7 5.9 Group 6 $ 43,558 $119.34 11.7 8.4 9.7 7.4 Group 7 $ 76,360 $209.21 20.5 14.7 17.1 13.0

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

Plan of Service

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

Plan of Service Development 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.

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

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

Christin Whitaker Department of Health and Mental Hygiene Community Options Administration Division 201 West Preston Street, Rm 136 Baltimore, MD 21201 christin.whitaker@maryland.gov 410-767-4449