Fillable Centres for medicare Community First Choice State Plan Option template 1915 k

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Centres for medicare Community First Choice State Plan Option template 1915 k

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Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
Benefit Summary:
Please provide a brief general overview of the state's proposed Community First Choice (CFC) benefit,
including but not limited to an overview of services, delivery method, impact on other long-term
services and supports (LTSS) programs, and how services will be coordinated between the CFC program
and other state services provided:
Community First Choice Development and Implementation Council
Name of State Development and Implementation Council:
Date of 1
st
Council meeting:
The state has consulted with its Development and Implementation Council before submitting its
CFC State Plan amendment.
The state has consulted with its Development and Implementation Council on its assessment of
compliance with home and community-based settings requirements, including on the settings
the state believes overcome the presumption of having institutional qualities.
The state has sought public input on home and community-based settings compliance beyond
the Development and Implementation Council. If yes, please describe.
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
Community First Choice Eligibility
Individuals are eligible for medical assistance under an eligibility group identified in the state
plan.
Categorically Needy Individuals
Medically Needy Individuals
Medically Needy individuals receive the same services that are provided to
Categorically Needy individuals
Different services than those provided to Categorically Needy individuals are
provided to Medically Needy individuals. (If this box is checked, a separate template
must be submitted to describe the CFC benefits provided to Medically Needy
individuals)
The state assures the following:
Individuals are in eligibility groups in which they are entitled to nursing facility services, or
If individuals are in an eligibility group under the state plan that does not include nursing facility
services, and to which the state has elected to make CFC services available (if not otherwise
required), such individuals have an income that is at or below 150 percent of the Federal
poverty level (FPL)
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
Level of Care
The state assures that absent the provision of home and community based attendant services
and supports provided under CFC, individuals would require the level of care furnished in a long-
term care hospital, a nursing facility, an intermediate care facility for individuals with intellectual
disabilities, an institution providing inpatient psychiatric services for individuals under age 21, or
an institution for mental diseases for individuals age 65 or over.
Recertification
The state has chosen to permanently waive the annual recertification of level of care
requirement for individuals in accordance with 441.510(c)(1) & (2).
Please indicate the levels of care that are being waived:
Long-term care hospital
Nursing facility
Intermediate care facility for individuals with intellectual disabilities
Institution providing psychiatric services for individuals under age 21
Institution for mental diseases for individuals age 65 or over
Describe the state process for determining an individual's level of care:
No
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
Informing Individuals Potentially Eligible for the Community First Choice Option
Indicate how the state ensures that individuals potentially eligible for CFC services and supports are
informed of the program's availability and services:
Letter
Email
Other – Describe:
Please describe the process used for informing beneficiaries:
Assurances (All assurances must be checked).
Services are provided on a statewide basis.
Individuals make an affirmative choice to receive services through the CFC option.
Services are provided without regard to the individual’s age, type or nature of disability, severity
of disability, or the form of home and community-based attendant services and supports that
the individual needs to lead an independent life.
Individuals receiving services through CFC will not be precluded from receiving other home and
community-based long-term care services and supports through other Medicaid state plan,
waiver, grant or demonstration authorities.
During the five-year period that begins January 1, 2014, spousal impoverishment rules are used
to determine the eligibility of individuals with a community spouse who seek eligibility for home
and community-based services provided under 1915(k).
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
CFC Service Models
Indicate which service models are used in the state's CFC program to provide consumer-directed home
and community-based attendant services and supports (Select all that apply):
Agency-Provider Model
Self-Directed Model with Service Budget
Other Service Model. Describe:
Please complete the following section if the state is using the Self-Directed Model with Service Budget
or the Other Service Model if it includes a Service Budget
Financial Management Services
• The state must make available financial management services to all individuals with a service
budget.
The state will claim costs associated with financial management services as:
A Medicaid Service
An Administrative Activity
The state assures that financial management service activities will be provided in accordance
with 42 CFR 441.545(B)(1). (Must check)
If applicable, please describe the types of activities that the financial management service entity will be
providing, in addition to the regulatory requirements at 42 CFR 441.545(B)(1).
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
Specify the type of entity that provides financial management services:
State Medicaid Agency
Another State Agency – Specify:
Vender Organization
Describe:
Other Payment Methods
The state also provides for the payment of CFC services through the following methods:
Use of Direct Cash Payments - The state elects to disburse cash prospectively to CFC
participants. The state assures that all Internal Revenue Service (IRS) requirements regarding
payroll/tax filing functions will be followed, including when participants perform the
payroll/tax filing functions themselves. Describe:
Vouchers- Describe:
Service Budget Methodology
Describe the budget methodology the state uses to determine the individual's service budget amount.
Also describe how the state assures that the individual's budget allocation is objective and evidence-
based utilizing valid, reliable cost data and can be applied consistently to individuals:
No
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
Describe how the state informs the individual of the specific dollar amount they may use for CFC
services and supports before the person-centered service plan is finalized:
Describe how the individual may adjust the budget, including how he or she may freely change the
budget and the circumstances, if any, which may require prior approval of the budget change from the
state:
Describe the circumstances that may require a change in the person-centered service plan:
Describe how the individual requests a fair hearing if his or her request for a budget adjustment is
denied or the amount of the budget is reduced:
Describe the procedures used to safeguard individuals when the budgeted service amount is insufficient
to meet the individual's needs:
Describe how the state notifies individuals of the amount of any limit to the individual's CFC services and
supports:
Describe the process for making adjustments to the individual's budget when a reassessment indicates
there has been a change in his or her medical condition, functional status, or living situation:
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
Mandatory Services and Supports
1. Assistance with activities of daily living(ADLs), instrumental activities of daily living (IADLs), and
health-related tasks through hand-on assistance, supervision, and/or cueing.
Identify the activities to be provided by applicable provider type and describe any service limitations
related to such activities.
Personal Attendant Services. Describe:
Provider Type:
License Required
Certification Required. Describe:
Education-Based Standard. Describe:
Other Qualifications Required for this Provider Type. Describe:
Companion Services. Describe:
Provider Type:
License Required. Describe:
Certification Required. Describe:
Education-Based Standard. Describe:
Other Qualifications Required for this Provider Type. Describe:
No
No
No
No
No
No
No
No
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
Homemaker/Chore Services. Describe:
Provider Type:
License Required. Describe:
Certification Required. Describe:
Education-Based Standard. Describe:
Other Qualifications Required for this Provider Type. Describe:
Other Services. Describe:
Provider Type:
License Required
Certification Required. Describe:
Education-Based Standard. Describe:
Other Qualifications Required for this Provider Type. Describe:
No
No
No
No
No
No
No
No
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
2. The acquisition, maintenance, and enhancement of skills necessary for the individual to
accomplish ADLs, IADLs, and health-related tasks.
Identify the activities to be provided by applicable provider type and any describe any service
limitations related to such activities:
Provider Type:
License Required. Describe:
Certification Required. Describe:
Education-Based Standard. Describe:
Other Qualifications Required for this Provider Type. Describe:
No
No
No
No
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
3. Individual back-up systems or mechanisms to ensure continuity of services and supports.
Identify the systems or mechanisms to be provided and limitations for:
Personal Emergency Response Systems
Pagers
Other Mobile Electronic Devices
Other. Describe:
Describe any limitations for the systems or mechanisms provided:
Provider Type:
License Required
Certification Required. Describe:
Education-Based Standard. Describe:
Other Qualifications Required for this Provider Type. Describe:
No
No
No
No
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
4. Voluntary training on how to select, manage and dismiss attendants.
The state will claim costs associated with voluntary training as (check one):
A Medicaid Service
An Administrative Activity
Describe the voluntary training program the state will provide to individuals on selecting, managing and
dismissing attendants:
Provider Type:
License Required
Certification Required. Describe:
Education-Based Standard. Describe:
Other Qualifications Required for this Provider Type:
No
No
No
No
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
Optional Services and Supports:
Indicate which of the following optional services and supports the state provides and provide a detailed
description of these benefits and any limitations applicable to them.
Transition Costs (Provided to individuals transitioning from a nursing facility, Institution for
Mental Disease, Intermediate care facility for Individuals with Intellectual Disabilities to a
community based home setting) – Check all of the following costs that apply:
Rental and Security Deposits
Description and Limitations:
Utility Security Deposits
Description and Limitations:
First Month’s Rent
Description and Limitations:
First Month’s Utilities
Description and Limitations:
Basic Kitchen Supplies
Description and Limitations:
No
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
Bedding and Furniture
Description and Limitations:
Other Household Items
Description and Limitations:
Other coverable necessities linked to an assessed need to enable transition from an institution
to the community
Description and Limitations:
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
Goods and Services - Services or supports for a need identified in the individual's person-
centered plan of services that increase an individual's independence or substitute for human
assistance, to the extent that expenditures would otherwise be made for the human assistance.
Include a service description including provider type and any limitations for each service
provided.
Home and Community Based Settings
Each individual receiving CFC services and supports must reside in a home or community-based
setting and receive CFC services in community settings that meet the requirements of 42 CFR
441.530
Setting Types (check all that apply):
CFC services are only provided in private residences and are not provided in provider - owned or
controlled settings.
CFC services may be provided in private residences and in provider owned or controlled
settings.
The CFC benefit includes settings that have been determined home and community-based
through the heightened scrutiny process.
No
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
Provider –owned or controlled settings:
1. Please identify all residential setting types in which an individual may receive services under the CFC
benefit.
2. Please identify all non-residential setting types in which a person may receive services under the CFC
benefit.
Setting Assurances– The state assures the following:
CFC services will be furnished to individuals who reside in a home or community setting, which
does not include a nursing facility, institution for mental diseases, an intermediate care facility
for individuals with intellectual disabilities, or a hospital providing long-term care services.
Any permissible modifications of rights within a provider owned and controlled setting is
incorporated into an individual’s person-centered service plan and meets the requirements of
42 CFR 441.530(a)(vi)(F).
Additional state assurances:
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
Community First Choice Support System, Assessment and Service Plan
Support System
The support system is provided in accordance with the requirements of §441.555.
Provide a description of how the support system is implemented and identify the entity or entities
responsible for performing support activities:
Specify any tools or instruments used as part of the risk management system to identify and mitigate
potential risks to the individual receiving CFC services:
Provide a description of the conflict of interest standards that apply to all individuals and entities, public
or private to ensure that a single entity doesn’t provide the assessments of functional need and/or the
person-centered service plan development process along with direct CFC service provision to the same
individual:
Conflict of Interest Exception: The only willing and qualified entity performing assessments of functional
need and or developing the person-centered service plan also provide home and community-based
services.
Provide a description, including firewalls, to be implemented within the entity to protect against conflict
of interest, such as separation of assessment and/or planning functions from direct service provision
functions, and a description of the alternative dispute resolution process:
No
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
Assessment of Need
Describe the assessment process or processes the state will use to obtain information concerning the
individual's needs, strengths, preferences and goals.
The state will allow the use of telemedicine or other information technology medium in lieu of a
face-to-face assessment in accordance with §441.535. The individual is provided with the
opportunity for an in-person assessment in lieu of one performed via telemedicine. Include a
description about how an individual receives appropriate support including access to on-site
support staff during the assessment:
The state will claim costs associated with CFC assessment activities as:
A Medicaid Service
An Administrative Activity
Indicate who is responsible for completing the assessment prior to developing the CFC person-centered
service plan. Also specify their qualifications:
Social Worker (specify qualifications)
Registered Nurse, licensed to practice in the state, acting within scope of practice under state
law.
Licensed Practical Nurse or Vocational Nurse, acting within scope of practice under state law
Licensed Physician (M.D. or O.D.), acting within scope of practice under state law
Case Manager (specify qualifications)
Other (specify what type of individual and their qualifications)
The reassessment process is conducted every:
12 months
Other (must be in increments of time less than 12 months)
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
Describe the reassessment process the state will use when there is a significant change in the
individual's needs or the individual requests a reassessment. Indicate if this process is conducted in the
same manner and by the same entity as the initial assessment process or if different procedures are
followed:
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
Person-Centered Service Plan
The CFC service plan must be developed using a person-centered and person- directed planning process.
This process is driven by the individual and includes people chosen by the individual to participate.
The state will claim costs associated with CFC person-centered planning process as:
A Medicaid Service
An Administrative Activity
Indicate who is responsible for completing the Community First Choice person-centered service plan.
Case Manager. Specify qualifications:
Social Worker. Specify qualifications:
Registered Nurse, licensed to practice in the state, acting within scope of practice under state
law.
Licensed Practical Nurse or Vocational Nurse, acting within scope of practice under state law.
Licensed Physician (M.D. or O.D.), acting within scope of practice under state law.
Other. Specify provider type and qualifications:
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
Person-Centered Service Plan Development Process: Use the section below to describe the process
that is used to develop the person-centered service plan.
Specify the supports and information that are made available to the individual (and/or family or
authorized representative, as appropriate) to direct and be actively engaged in the person-centered
service plan development process and the individual’s authority to determine who is included in the
process:
Indicate who develops the person-centered service plan. Identify what individuals, other than the
individual receiving services or their authorized representative, are expected to participate in the
person-centered service plan development process. Please explain how the state assures that the
individual has the opportunity to include participants of their choice:
Describe the timing of the person-centered service plan development to assure the individual has access
to services as quickly as possible; describe how and when it is updated, including mechanisms to address
changing circumstances and needs or at the request of the individual:
Describe the state's expectations regarding the scheduling and location of meetings to accommodate
individuals receiving services and how cultural considerations of the individual are reflected in the
development of the person-centered service plan:
Describe how the service plan development process ensures that the person-centered service plan
addresses the individual's goals, needs (including health care needs), and preferences and offers choices
regarding the services and supports they receive and from whom. Please include a description of how
the state records in the person-centered service plan the alternative home and community based
settings that were considered by the individual:
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
Describe the strategies used for resolving conflict or disagreements within the process:
Please describe how the person-centered service plan development process provides for the assignment
of responsibilities for the development of the plan and to implement and monitor the plan.
The state assures that assessment and service planning will be conducted according to
441.540(B) 1-12.
The person-centered service plan is reviewed and updated every:
3 months
6 months
12 months
Other (must be less than 12 months)
AND
When an individual's circumstances or needs change significantly or at the individuals request.
Describe the person-centered service plan review process the state will use. In the description please
indicate if this process is conducted in the same manner and by the same entity as the initial service plan
review process or if different procedures are followed:
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
Community First Choice Service Delivery Systems
Identify the service delivery system(s) that will be used for individuals receiving CFC services:
Traditional State-Managed Fee-for-Service (4.19(b) page is required)
Managed Care Organization
Other
Describe:
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
Quality Assurance System
Please describe the state's quality improvement strategy:
Describe the methods the state will use to continuously monitor the health and welfare of each
individual who receives home and community-based attendant services and supports, including a
process for the mandatory reporting, investigation, and resolution of allegations of neglect, abuse, or
exploitation in connection with the provision of such services and supports:
Describe how the state measures individual outcomes associated with the receipt of home and
community-based attendant services and supports as set forth in the person centered service plan,
particularly for the health and welfare of individuals receiving such services and supports. (These
measures must be reported to CMS upon request.)
Describe the standards for all service delivery models for training, appeals for denials and
reconsideration procedures for an individual’s person-centered service plan:
Describe the methods used to monitor provider qualifications:
Describe the methods for assuring that individuals are given a choice between institutional and
community based services:
Describe the methods for assuring that individuals are given a choice of services, supports and
providers:
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
Describe the methods for monitoring that the services and supports provided to each individual are
appropriate:
Describe the state process for ongoing monitoring of compliance with the home and community-based
setting requirements, including systemic oversight and individual outcomes:
Choice and Control
Describe the quality assurance system's methods to (1) maximize consumer independence and control,
(2) provide information about the provisions of quality improvement to each individual receiving CFC
services and supports:
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
Stakeholder Feedback
Describe how the state will elicit feedback from key stakeholders to improve the quality of the
community-based attendant services and supports benefit:
Identify the stakeholders from whom the state will elicit feedback:
The state will elicit feedback from the following stakeholders: (1) Individuals receiving CFC
services and if applicable, their representatives, (2) disability organizations, (3) providers, (4)
families of elderly individuals or individuals with disabilities, (5) and members of the community
Other
Describe:
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
State Assurances
The state assures there are necessary safeguards in place to protect the health and welfare of
individuals provided services under this state Plan Option, and to assure financial accountability
for funds expended for CFC services.
With respect to expenditures during the first full year in which the state plan amendment is
implemented, the state will maintain or exceed the level of state expenditures for home and
community-based attendant services and supports provided under section 1905(a), section
1915, section 1115, or otherwise to individuals with disabilities or elderly individuals
attributable to the preceding year.
The state assures the collection and reporting of information, including data regarding how the
state provides home and community-based attendant services and supports and other home
and community-based services, the cost of such services and supports, and how the state
provides individuals with disabilities who otherwise qualify for institutional care under the state
plan or under a waiver the choice to instead receive home and community-based services in lieu
of institutional care, and the impact of CFC on the physical and emotional health of individuals.
The state shall provide the Secretary with the following information regarding the provision of
home and community-based attendant services and supports under this subsection for each
fiscal year such services and supports are provided:
(i) The number of individuals who are estimated to receive home and community-based
attendant services and supports under this option during the fiscal year.
(ii) The number of individuals that received such services and supports during the
preceding fiscal year.
(iii) The specific number of individuals served by type of disability, age, gender, education
level, and employment status.
(iv) Whether the specific individuals have been previously served under any other home
and community based services program under the state plan or under a waiver.
The state assures that home and community-based attendant services and supports are
provided in accordance with the requirements of the Fair Labor Standards Act of 1938
and applicable Federal and state laws.
According to the Paperw ork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-
1148 (CMS-10398 #50). The time required to complete this information collection is estimated to average 10 hours
per response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please w rite to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
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Centres for medicare Community First Choice State Plan Option template 1915 k

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Completed 24 December 2019

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