NYS Department of Health Announces Plan to Add Community First Choice Option to State Medicaid Plan

On March 18, 2011, Commissioner of Health, Nirav R. Shah, M.D., M.P.H., announced that the Health Department would begin the process of amending the State Medicaid Plan to add a new federal model for community based long term care.  The new program, called the Community First Choice Option, will be targeted at providing long term care to elderly and disabled populations in individual homes and community-based residences.

The Community First Choice Option was added to the federal Medicaid statute by Sec. 2401 of the Patient Protection and Affordable Care Act of 2010, Pub. L. 111-148 (“ACA”).  It is intended to expand upon the existing personal care services available under the ACA, including consumer-directed services and home and community based service waiver programs.  To be approved, states must offer the program on a statewide basis, and “without regard to the [beneficiary’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 in order to lead an independent life.” ACA § 2401.

The ACA outlines the scope of services that will be available under the Community First Choice Option by describing required, optional, and prohibited services.

Required services include:

  • assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs) and health related tasks;
  • training in ADLs, IADLs and health related tasks;
  • the provision of mechanisms to ensure continuity of services such as beepers or other electronic devices; and
  • voluntary training on how to select, manage and dismiss attendants.

Optional services, which states can elect to provide, include:

  • costs incurred in transitioning from an institutionalized setting; and
  • services that meet a catch-all provision encompassing any services identified in the individualized service plan that increase “independence or substitute for human assistance,” to the extent that such services offset the cost of services that would have been provided under the plan.

Excluded services include:

  • room and board costs;
  • special education services provided under the Individuals with Disabilities Education Act (IDEA);
  • vocational rehabilitation services provided under the Rehabilitation Act of 1973;
  • assistive technology devices other than those needed to ensure continuity of services;
  • medical supplies and equipment; and
  • home modifications. 

Two other important elements of the Community First Choice Option are that services must be provided in community-based residences or in recipients’ homes, and that the services must be consumer directed.  The ACA provides that individuals admitted to a hospital, nursing home, intermediate care facility, or mental health institution are not eligible for the program.  Consumer directed, also referred to as self-directed, means that the beneficiary or his or her representative has a central role in service planning and has the authority to make hiring, firing and training decisions for his or her attendant.  The specific eligibility requirements and the scope of available services will become clearer once federal and state regulations are published interpreting the statute.  The federal Centers for Medicare and Medicaid Services (“CMS”) has started that process, publishing proposed regulations in the Federal Register on February 25, 2011.  We will review these proposed regulations in another post.

Commissioner Shah’s announcement simply marks the start of the process of adding the Community First Choice Option to the New York plan.  The ACA requires states to form an implementing council, composed of eligible beneficiaries and their representatives, as part of the process.  The Department of Health is currently accepting nominations for the council.  Once the implementation council is formed, the State must collect certain information required by the ACA and draft a proposed amendment to the State Medicaid Plan.  Finally, CMS must approve the amendment before New Yorkers can utilize this new care model.

We will continue to cover important developments related to the Community Choice First Option.

This post was contributed by Nancy Sciocchetti.