The Affordable Care Act and The Community First Choice Option
Author: Wendy Taormina-Weiss
Published: 2012-04-27 : (Rev. 2013-08-01)
Synopsis and Key Points:
Different states in America can provide services to people who are eligible for Medicaid whose incomes do not exceed 150% of poverty.
Main DigestA new, state-based option with the goal of providing home and community-based services in relation to Medicaid-eligible Section 1915 became available on October 1st of 2011. The option is known as the, 'Community First Choice Option,' and states in America that take up this option receive a 6 point increase in federal matching payments (FMAP) for costs associated with the program.
Community First Choice Option - A new state plan option to provide home- and community-based services in Medicaid Section, 1915(k); available October 1, 2011. States that take up this option receive a 6 percentage point increase in federal matching payments (FMAP) for costs associated with the program.
The Affordable Care Act - The Affordable Care Act puts in place strong consumer protections, provides new coverage options and gives you the tools you need to make informed choices about your health. The health care law puts in place reforms that will roll out through 2014 and beyond.
The different states in America can provide services to people who are eligible for Medicaid whose incomes do not exceed 150% of poverty. The states that have set a higher income eligibility level for Medicaid for people who require care in an institution can use that higher income level. A state must make a determination; however, that but for the provision of home and community-based services, a person would need nursing institution care.
What Kinds of Benefits are Associated with the Community First Choice Option
Home and community-based attendant services would be provided to eligible people in their own communities. Services for people would be based upon a person's individual care plan, something that is developed through an assessment of the person's functional needs. There would be no restrictions on a state's program expenditures. States that pursue the Community First Choice Option have to provide eligible people with the following:
- Voluntary training in regards to the hiring and dismissal of attendants
- Assistance with both the activities and instrumental activities of daily living
- Assistance with health-related tasks to include hands-on assistance, queuing, and supervision
- Backup systems such as beepers which will ensure the continuity of the person's care and support
- Assistance with the acquisition, maintenance, and enhancement of skills to complete ADL's and health-related tasks
The different states in America, at their choosing, may also offer some optional services to people who are eligible for the Community First Choice Option. For example; a state might offer to pay the costs of transitioning a person from an institution to their own community - first month's rent, utility deposits, additional rent, bedding, kitchen supplies, or other needed items. A state may also choose to pay for additional items that have been noted in a person's individual care plan that will increase their independence, or substitute for personal assistance, such as backup systems. States would not; however, pay for home modifications, medical supplies, room and board, or types of assistive technologies that do not meet the definition of backup systems.
Who Provides the Services
Services related to the Community First Choice Option may be provided under an agency or other model. Family members; who meet the definition by the Department of Health and Human Services, can provide services. Providers will be selected, and services will be controlled, by the eligible person or their representative to the greatest extent possible. The states have to make sure that despite the care model, the services a person is provided with are provided in accordance with the Fair Labor Standards Act. The states have to meet some different requirements in relation to the Community First Choice Option, to include the following.
Maintenance of State Effort: During the first year, a state has to maintain or exceed its prior year of Medicaid expenditures for optional services it provided to people with disabilities and seniors.
Quality Systems and Data Measures: States have to develop quality systems that incorporate consumer feedback and monitor health measures. States also have to submit program reports to the Department of Health and Human Services.
A Development and Implementation Council: States have to establish a Development and Implementation Council in order to collaborate on program design and implementation. The council has to have a majority membership of people with disabilities, seniors, or our representatives.
Availability of Services: Participating states have to make services available throughout the state. The services must be available with no caps or targeting by a person's age, the severity of the form of disability the person experiences, or any other criteria. The services the state provides have to be provided in the most integrated setting appropriate to meet the person's needs.
At this time, states in America have the option to provide people with disabilities and seniors with personal care services through Medicaid plans; 35 states do so. The Community First Choice Option expands on the programs states are offering, allowing them to open eligibility to people who have higher incomes than poverty level while offering more services. The increased federal matching payment presents a strong incentive for states to take up the option and expand their home and community-based care services through Medicaid. The Community First Choice Option presents states with the opportunity for wider expansion of their home and community-based services, something that is very greatly needed and desired by people with disabilities and seniors.
Studies have shown that provision of care in a person's own home or in their own community can lead to better outcomes. Secretary Sebelius, in regards to the Affordable Care Act and the Community First Choice Option stated, "We know that people frequently prefer to receive services in their own homes and communities whenever possible. The rule and demonstration announced today give people choice and provide states with flexibility to design programs that better meet the needs of beneficiaries. Prior to passage of the Affordable Care Act, many families had few choices beyond nursing homes or other institutions for their loved ones. The actions taken today will help change that and can lead to better health for these individuals."
The Department of Health and Human Services has finalized the Community First Choice rule and is pursuing an, 'Independence At Home Demonstration,' program which encourages primary care practices that are provided through home-based care to chronically ill persons. A number of organizations are participating in the demonstration program, testing whether delivering primary care services in a person's home can improve the quality of their care while reducing costs. The organizations were selected from a competitive pool of applications from hundreds of health care providers who were interested.
The Independence At Home demonstration program also partners with primary care practices led by physicians or nurse practitioners to evaluate the extent to which delivery of primary care services in a person's home is effective in improving care for people with multiple chronic conditions while reducing costs. Up to 10,000 people with chronic conditions will be able to receive the majority of the health care they need at home through the demonstration program, which will run from June 1st of 2012 through May 31st of 2015.
The Department of Health and Human Services also wants your comments about a proposed rule that describes a separate Home and Community-based Services state plan option. Like the Community First Choice Option, the benefit will make it easier for states to provide Medicaid coverage for home and community-based services.
Acting CMS Administrator Marilyn Tavenner says, "Our goal is to provide person-centered support to every Medicare and Medicaid beneficiary, regardless of their physical ability or chronic health conditions. These services and programs will help keep these individuals' health stable, and keep them home where they want to be, while giving us even more tools to achieve better care for the patient, better health for the population, all at lower costs."
Secretary Sebelius has also announced the creation of the new, 'Administration for Community Living,' something that brings together key Health and Human Services offices and organizations that are dedicated to the improvement of the lives of Americans with functional needs into one coordinated and stronger entity. The agency will work with the goal of increasing access to community supports for people with disabilities and seniors while achieving our full community participation.
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