Community First Choice Option (CFCO)

Local District Social Service Office Training

Fee for Service Rates for Community First Choice Options

January 8, 2019

Agenda

Overview of Community First Choice Option (CFCO)

  • Community First Choice Option (CFCO) became available to all states under the Affordable Care Act of 2010. This option provides a six percent (6%) point increase in federal matching payments to states to expand and enhance Medicaid State Plan (State Plan) home and community based attendant services to individuals in need of long–term care for Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs) and health–related tasks. The LDSS will now be required to administer the CFCO through adherence to the State Plan, 42 CFR Part 441, and State–issued guidance, which will ensure statewide consistency when authorizing or reauthorizing CFCO services.
  • All services must be provided statewide in a manner that provides such services in the most integrated setting appropriate to the individual´s needs, and 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 requires to lead an independent life.
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ADMs

  • The initial ADM dated 4/1/18 is currently completing a second period of review and comments from Districts. It will be ready for statewide distribution as soon all comments are received and it completes the internal process necessary for all ADMs.
  • A draft copy of the 4/1/18 ADM is available here.
    This draft copy does not contain the current comments.
  • The next phase in changes for the LDSS is the pending approval of the Children´s Consolidated 1915c Waiver scheduled for 4/1/19.
  • As a result of the approval of the 4/1/19 Consolidated Children´s 1915c Waiver, CFCO state plan services will be uniformly available to all eligible waiver individuals. These services, Assistive Technology, Environmental Modifications and Vehicle Modifications, are currently not available in all of the individual waivers.
  • Those three services will become available on 4/1/19 and will be the responsibility of the Local Districts to authorize and provide these services for any eligible individual enrolled in the Consolidated Children´s 1915c.
  • For individuals who are enrolled in both the new 1915c Consolidated Waiver and in a managed care plan, the Local Districts will be responsible for providing these services until these services are implemented into the Managed Care benefit package on 7/1/19
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Roles and Responsibilities

  • In the Medicaid Fee–for–Service (FFS) environment, oversight, assessment, reassessment and service planning for individuals seeking CFCO services will be the responsibility of the LDSS.
  • The Local Departments of Social Service (LDSS) will be responsible for identifying and authorizing all State Plan services in the CFCO menu and working with other entities to authorize other services for which the individual may be eligible based on his or her functional needs assessment and person–centered service plan.
  • The Local Departments of Social Service (LDSS) will also be responsible for billing for the services they provide. Additional webinars will be scheduled to discuss specific pathways for reimbursement.
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Current CFCO Services

  • Current CFCO Services
    • Consumer Directed Personal Assistance Services (CDPAS)
    • Home Health Aide
    • Homemaker/Housekeeper (Personal Care Level 1)
    • Personal Care Level 2
    • Personal Emergency Response System (PERS)
    • Non–Emergency Medical Transportation (NEMT)

Implementation of Additional CFCO Services

  • Implementation for July 1, 2019:
    • Assistive Technology (At)
    • Environmental Modification (E–Mod)
    • Vehicle Modification (V–Mod)
    • Moving Assistance
    • Community Transitional Services (CTS)
    • Skill Acquisition Maintenance and Enhancement (SAME)
    • Home–Delivered/Congregate Meals

Assistive Technology:

July 1, 2019 Implementation

  • Definition: Assistive Technology (AT) is defined as an item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or to improve the functional capabilities of the individual, and/or enhance an individual´s independence in performing activities of daily living (ADLs), instrumental activities of daily living (IADLs) and health–related tasks. The use of the AT must increase a consumer´s independence or substitute for human assistance that would otherwise be authorized (e.g., personal care services). AT does not include items that are covered within the scope of durable medical equipment.
  • Service Limit: AT costs cannot exceed $15,000 per year without prior approval from the New York State Department of Health
    Rate Code for Assistive Technology
    Rate Code Description Effective Date HCPCS Code
    3186 ASSISTIVE TECHNOLOGY (AT) – CFCO 7/1/2019 T2028

Skill Acquisition, Maintenance and Enhancement (SAME)

July 1, 2019 Implementation

  • Definition: Services that include adaptive skill development, hands–on assistance with ADLs; community inclusion and relationship building; training and support for independence in travel; transportation; adult educational supports; social and leisure development; self–advocacy and informed choice skill development; and appropriate behavior development to help the individual live independently in their community. These services, necessary to promote independence and community integration, can be delivered at any non–certified location in the community, including the individual´s home. Acquisition is described as the service available to a physical and mentally capable individual who is thought to be capable of achieving greater independence by potentially learning to perform the task for him or herself. There should be a reasonable expectation that the individual will acquire the skills necessary to perform that task within the authorization period.

    Maintenance is described as the service available to prevent regression in the individual´s skill level and to also prevent loss of skills necessary to accomplish the identified task. Enhancement activities are provided to the individual through training and demonstration to promote growth and independence with an already acquired skill level and to support the participant´s goal.
  • Authorization Guidelines: Skill acquisition, maintenance and enhancement are face–to–face services that are determined by a functional needs assessment and must be identified in the member/recipient´s PCSP
FFS – S.A.M.E (Personal Care – Level 2)
Rate Code Description Effective Date HCPCS Code
2501 PCA LEVEL 1, SHARED AIDE, BASIC, HOURLY No change to the current rate TBD
2502 PCA LEVEL II, SHARED AIDE, BASIC, HOURLY No change to the current rate TBD
2507 PCA LEVEL 1, SHARED AIDE, BASIC, QUARTER HOUR No change to the current rate TBD
2508 PCA LEVEL II, SHARED AIDE, BASIC, QUARTER HOUR No change to the current rate TBD
2593 PCA LEVEL I, 1 CLIENT, QUARTER HOUR No change to the current rate TBD
2594 PCA LEVEL I, 2 CLIENTS, PER CLIENT 1/4 HOUR No change to the current rate TBD
2595 PCA LEVEL II, 1 CLIENT, 1/4 HOUR No change to the current rate TBD
2596 PCA LEVEL II, 2 CLIENTS PER CLIENT 1/4 HOUR No change to the current rate TBD
2597 PCA LEVEL II, 1 CLIENT, HARD TO SERVE, 1/4 HOUR No change to the current rate TBD
2598 PCA LEVEL II, 2 CLIENTS, HARD TO SERVE 1/4 HOUR No change to the current rate TBD
2601 PCA LEVEL I, ONE CLIENT HOURLY No change to the current rate TBD
2602 PCA LEVEL 1 TWO CLIENTS HOURLY No change to the current rate TBD
2623 PCA LEVEL 2 TWO CLIENTS HOURLY No change to the current rate TBD
2622 PCA LEVEL 2 ONE CLIENT HOURLY No change to the current rate TBD
2626 PCA LEVEL 2 ONE CLIENT HOURLY– SECONDARY CODE No change to the current rate TBD
2627 PCA LEVEL 2 2 CLIENTS HOURLY– PER CLIENT, SECONDARY CODE No change to the current rate TBD
2632 PCA LEVEL 2, ONE CLIENT DAILY No change to the current rate TBD
2633 PCA LEVEL 2, 2 CLIENTS DAILY (PER CLIENT) No change to the current rate TBD
FFS S.A.M.E – (CDPAP)
Rate Code Description Effective Date HCPCS Code
2401 CDPAP 1 CLIENT, HOURLY No change to the current rate TBD
2402 CDPAP 2 OR MORE CLIENTS HOURLY, PER CLIENT No change to the current rate TBD
2403 CDPAP 1 CLIENT, HOURLY, ENHANCED No change to the current rate TBD
2404 CDPAP 2 OR MORE CLIENTS HOURLY PER CLIENT EN No change to the current rate TBD
2405 CDPAP 1 CLIENT LIVE–IN No change to the current rate TBD
2406 CDPAP 2 OR MORE CLIENTS, PER CLIENT LIVE–IN No change to the current rate TBD
2422 CDPAP 1 CLIENT, QUARTER HOUR No change to the current rate TBD
2423 CDPAP 2 CLIENTS, PER CLIENT, QUARTER HOUR No change to the current rate TBD
2424 CDPAP 1 CLIENT ENHANCED RATE QUARTER HOUR No change to the current rate TBD
2425 CDPAP 2 CLIENTS, PER CLIENT,ENHANCED RATE QUARTER HOUR No change to the current rate TBD

Companion Add–on Rate Codes for SAME
Rate Code Description Effective Date HCPCS Code
3171 ADL/IADL SKILL ACQUISITION SVCS – CFCO NON–DD As of 7/1/19 HCPCS code TBD

Home Health Aides

  • Home health Aide Rate codes for all mandatory CFCO services are the responsibilities of the CHHAs.
  • CHHAs will bill for certified home health aides using their appropriate rate codes. For counties without their own CHHAs, a comprehensive list of all CHHAs and the counties they service can be found here.

Environmental Modification (E–Mod):

July 1, 2019 Implementation

  • Definition: 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, to the extent that expenditures would otherwise be made for the human assistance.
  • Service Limit: Contracts for environmental modifications may not exceed $15,000 without prior approval of DOH
    Rate Code for Environmental Modifications
    Rate Code Description Effective Date HCPCS Code
    3192 ENVIRONMENTAL MODIFICATIONS – CFCO As of 7/1/19 TBD

Vehicle Modification (V–Mod)

July 1, 2019 Implementation

  • Definition: This service covers the cost of modifications to a vehicle if it is the primary means of transportation for the consumer. The vehicle may be owned by the consumer or by a family member or non–relative who provides primary, consistent and ongoing transportation for the consumer. Modifications are approved only when they are necessary to increase the consumer´s independence and inclusion in the community
  • Service Limit: Contracts for vehicle modifications may not exceed $15,000 without prior approval of DOH
    Rate Code for V Mods
    Rate Code Description Effective Date HCPCS Code
    3193 VEHICLE MODIFICATIONS – CFCO As of 7/1/19 TBD

Home–Delivered/Congregate Meals

July 1, 2019 Implementation

  • Definition: Meals provided to an individual who cannot prepare or obtain nutritionally adequate meals for themselves, or when the provision of such meals will decrease the need for more costly supports to provide in–home meal preparation. This benefit may include up to two meals a day.
  • Authorization Guidelines: This service is reimbursed on a per meal basis
    Rates for Home Delivered and Congregate Meals
    Rate Code Description Effective Date HCPCS Code
    3183 HOME DELIVERED MEALS – CFCO 7/1/2019 S5170
    3184 CONGREGATE MEALS – CFCO 7/1/2019 S9977
    3185 HOME DELIVERED MEALS– (WKND)– CFCO 7/1/2019 S5170

Community Transitional Services (CTS)

July 1, 2019 Implementation

  • Definition: Individually designed services intended to assist a member/recipient to transition from an institutional setting to an appropriate home and community–based setting.
  • Service Limit: Costs are limited to a one–time expense of up to $5,000
    RATE CODE FOR CTS
    Rate Code Description Effective Date HCPCS Code
    3187 COMMUNITY TRANSITION SERVICES (CFCO) 7/1/2019 T2038

Moving Assistance

July 1, 2019 Implementation

  • Definition: Individually designed service intended to transport the possessions and furnishings of a CFCO–eligible member/recipient who is moving from an institutional environment into a community–based setting. Moving assistance must be based on the assessed needs of the member/recipient and support his/her desires and goals as outlined in the Person–Centered Service Plan (PCSP). This service includes the cost of moving furniture and other belongings.
  • Service Limit: Moving Assistance is limited to a one–time expenditure of $5,000
    RATE CODE FOR MOVING ASSISTANCE
    Rate Code Description Effective Date HCPCS Code
    3188 MOVING ASSISTANCE (HOURLY) –CFCO 7/1/2019 T2038
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CFCO Eligibility Criteria

  • An individual eligible to receive CFCO services must:
    • Be Medicaid eligible for community coverage with community–based long term care (with or without a spend down) or be Medicaid eligible for coverage of all care and services;
    • Have an assessed institutional level of care; and
    • Reside in his/her own home, or the home of a family member.
  • Individual´s Medicaid eligibility may not be dependent on:
    • Spousal impoverishment post–eligibility rules;
    • The Special Income Standard for Housing Expenses; or
    • Family of one budgeting for a child participating in a HCBS Waiver (State is seeking CMS approval to allow family of one children under the proposed consolidated Children´s 1915(c) Waiver to be eligible for CFCO services)

All CFCO Services Must be Provided in a Home or Community Based Setting

  • All CFCO services must be provided in a home or community–based setting
    • All CFCO services must be provided in settings that comply with 42 CFR §441.530
    • Settings include the individual´s own home or a family member´s home that meet the settings criteria outlined in 42 § CFR 441.530
    • Does not include a nursing facility, hospital providing long-term care services, institution for mental disease, intermediate care facility for individuals with an intellectual disability or related condition, or setting with the characteristics of an institution
    • Does not include provider&I#8211;owned or controlled residential settings
  • HCBS recipients must live in compliant settings, regardless of where the services are provided
  • Must follow New York´s Statewide Transition Plan for HCBS Settings (approved by CMS on November 18, 2018)

Consolidated Children´s Waiver and CFCO

  • The Consolidated Children´s Waiver is now before CMS
    • Anticipated approval is April 1, 2019
  • The Children´s Waiver authorizes an array of HCBS that include AT, V-Mods, E- Mods and SAME (Community Habilitation)
  • The service definitions for these services in the Consolidated Children´s Waiver are aligned with the CFCO services
  • The process for accessing these services April 1, 2019 under the Children´s Waiver will be the same as processes outlined here for CFCO
    • Additional guidance will be distributed under the Children´s Waiver
CFCO Services Available in 1915(c) Waiver Services Today
  Current Services that will Remain in Effect Under 1915(c) with Implementation of CFCO Services Current Children´s 1915(c) Waivers Effective Now Thru 3/31/19* *Effective 4/1/19 with CMS Approval
CFCO Services MLTC TBI
Waiver		 NHTD
Waiver		 OPWDD
Comprehensive
Waiver		 OPWDD
CAH		 DOH
Care at
Home
(CAH) I/II		 OCFS B2H
(MF, DD,
SED)		 Consolidated
Children´s Waiver
Assistive Technology (AT)   X X X X   X X
Vehicle Modifications   X X X (Part of AT) X X X
Environmental Modifications X X X X X X X X
Moving Assistance     X          
Community Transitional Services   X X X        
Home–Delivered/ Congregate Meals X   X          
Skill Acquisition Maintenance and Enhancement (SAME)/ Community Habilitation(CH)             X X
KIDS CAH I & II
Rate Code Description Effective Date HCPCS Code
8037 ADAPTIVE AND ASSISTIVE EQUIPMENT – $1.00 UNIT As of 4/1/2019 (Upon Approval of Waiver) T2028
8038 ADAPTIVE AND ASSISTIVE EQUIPMENT – $10.00 UNIT As of 4/1/2019 T2028
8039 ADAPTIVE AND ASSISTIVE EQUIPMENT – $100.00 UNIT As of 4/1/2019 T2028
8040 ADAPTIVE AND ASSISTIVE EQUIPMENT – $1000.00 UNIT As of 4/1/2019 T2028

New Rate Codes for KIDS 1115 for Environmental Modifications
Rate Code Description Effective Date HCPCS Code
8032 ACCESSIBILITY MODIFICATIONS – $1.00 UNIT As of 4/1/2019 (Upon Approval of Waiver) S5165
8034 ACCESSIBILITY MODIFICATIONS – $10.00 UNIT As of 4/1/9 S5165
8035 ACCESSIBILITY MODIFICATIONS – $100.00 UNIT As of 4/1/9 S5165
8036 ACCESSIBILITY MODIFICATIONS – $1000.00 UNIT As of 4/1/9 S5165

KIDS 1115 New Rate Codes V Mods
Rate Code Description Effective Date HCPCS Code
8041 VEHICLE MODIFICATIONS – $1.00 UNIT As of 4/1/2019 (Upon Approval of Waiver) T2039
8042 VEHICLE MODIFICATIONS – $10.00 UNIT As of 4/1/19 T2039
8043 VEHICLE MODIFICATIONS – $100.00 UNIT As of 4/1/19 T2039
8044 VEHICLE MODIFICATIONS – $1000.00 UNIT As of 4/1/19 T2039

LCSS Services

  • Individuals participating in other waivers will continue to receive their services without change.

    NOTE: Individuals enrolled in current 1915(c) Waivers that may not meet CFCO eligibility criteria, but do meet the criteria of Waivers, will continue to access these services under the authority of the 1915(c) Waiver
  • Please note the accompanying chart to show who is responsible for authorizing and providing services
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CFCO Service Authorization for Fee–for–Service individuals – July 1, 2019
(individuals NOT Enrolled in Managed Care Plan)
FFS Population AT E–MOD V–MOD SAME/CH Home/
Congregate Meals		 CTS Moving
Assistance
OPWDD Comprehensive Waiver DDRO DDRO DDRO DDRO LDSS DDRO DDRO
OPWDD Individuals with RE 95 not in the OPWWD Waiver, (applies to adults and children) DDRO** DDRO DDRO DDRO LDSS DDRO DDRO
1915(c) Consolidated Children´s Waiver * LDSS LDSS LDSS LDSS LDSS LDSS LDSS
Nursing Home Transition and Diversion Waiver RRDC*** RRDC RRDC LDSS RRDC RRDC RRDC
Traumatic Brain Injury Waiver RRDC RRDC RRDC LDSS LDSS RRDC LDSS
All other FFS individuals LDSS LDSS LDSS LDSS LDSS LDSS LDSS

* Upon CMS approval will take effective April 1, 2019 – Service authorization will be the same as CFCO service authorization
** Developmental Disabilities Regional Office
***Regional Resource Development Center

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Rate Codes and Charges for CFCO Services

  • As part of CFCO, the permissible services listed in this presentation will become part of the State Plan and will be available to all qualified individuals on 7/1/19.
  • Further training sessions will be available. The next scheduled sessions deal with Restriction/Exception Codes and how they are intertwined with CFCO claiming and eligibility
  • Those trainings are scheduled for January 17th between 1:00–2:00 pm for districts and January 18th between 1:00 –2:00 pm for the Managed Care Plans
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Questions may be submitted to our mailbox

CFCO@health.ny.gov

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