Understanding Medicaid's Community First Choice Program

Community First Choice offers home health care without the limitations of the Home and Community-Based Services (HCBS) waiver.

By , J.D. · University of Virginia School of Law

Community First Choice (CFC) is a Medicaid program that was created by the Affordable Care Act (ACA) to make it easier for states to offer home- and community-based services to Medicaid beneficiaries. (The ACA added the CFC program to the Social Security Act, under Section 1915(k).) States that choose to run CFC programs will get increased federal matching funds to provide care attendants and supports to Medicaid beneficiaries who would otherwise need to be institutionalized.

The CFC program requires states to allow Medicaid beneficiaries to direct their own care as much as possible. Under CFC, the Medicaid beneficiary should have the authority to interview care attendants, choose the best one, and fire that person if necessary.

Who Is Eligible for Community First Choice?

Here are the various eligibility rules for Community First Choice.

Your state. You cannot receive Community First Choice services unless you live in a state that has chosen to offer CFC. As of late 2013, only eight states had decided to offer the CFC option in their Medicaid plans: Arkansas, Arizona, Oregon, California, New York, Montana, Minnesota, and Maryland. These states are in different stages of implementing the program.

Income limits. If you live in one of these states and want to receive CFC services, you have to meet Medicaid eligibility requirements in your state. However, low-income individuals whose income is too high to qualify for Medicaid may still qualify for CFC services. The CFC program serves individuals whose income does not exceed 150% of the federal poverty level (FPL). (In contrast, starting in January 2014, the uniform income level for Medicaid eligibility is 133% FPL. For the figures these percentages represent, see Nolo's article on the various limits that are tied to the FPL.)

Note that some states already have income limits that are higher than 150% FPL for certain groups of people who require institutional care. In those states, the higher income limits also apply for CFC services.

Need for care. You must need an "institutional" level of care before you can qualify for CFC services. You meet an institutional level of care if, without the home- and community-based services, you would need to be in an institution like a nursing home. If your state offers a CFC program, it will evaluate your level of care needs when you apply for services.

No other limits allowed. Unlike other Medicaid home- and community-based options available to states (for example, the Home and Community-Based Services (HCBS) waiver), CFC specifically prohibits states from limiting the program by only offering it to certain types of people or to certain communities. If CFC is available in your state, then it is available to you regardless of your age, disability, or where you live in the state. Also, the program does not permit the state to cap enrollment, so the program is available to as many qualified people as apply for it.

Services Provided by the Community First Choice Program

Under the CFC program, states are required to provide home- and community-based services to Medicaid beneficiaries to enable them to avoid institutionalization, but they have some flexibility about how to provide these services.

States can use what Medicaid calls an "agency-provider model," in which Medicaid beneficiaries rely on an agency to help them locate, select, and manage the services they need to stay in their homes. Alternatively, states can use what Medicaid calls a "self-directed model," in which Medicaid beneficiaries are responsible for locating, selecting, and managing their own services. States can also use another model for delivering CFC services, as long as they get approval from the Centers for Medicare and Medicaid Services (CMS) first.

States also have some choice in the types of services they offer in their CFC programs. Some services are mandatory, and some are optional.

Mandatory Services

In a CFC program, you can get services that help you with activities of daily living (ADLs) and with instrumental activities of daily living (IADLs). ADLs are activities that you need to do to be able to live, like moving from place to place, using the toilet, washing, feeding yourself, and eating. IADLs are activities that you need to do to be able to live independently, even though they are not quite as fundamental as ADLs. Some examples of IADLs are housecleaning, shopping, and managing your money. CFC programs must offer help with both ADLs and IADLs according to your specific needs.

In addition, CFC programs must offer help with health-related tasks like organizing medication and helping you take it or helping you maintain medical devices that you need.

CFC programs are required to pay for back-up systems to ensure that you always have the care that you need. Examples of back-up systems are beepers or medical alert buttons.

CFC programs are also required to offer you training on how to hire, manage, and fire your attendants. One of the goals of the CFC program is to put Medicaid beneficiaries in control of their own care as much as possible, and allowing beneficiaries the chance to choose their own care attendants is an important part of the program.

Optional Services

States can also offer other services in their CFC programs. Optional services include payment of costs needed to transition out of an institution (like first month's rent, security deposits, moving expenses, or funds for bedding or kitchen supplies) and payment for services or items needed to increase independence and decrease the need for a care attendant (like a bus pass or a microwave).

How to Apply for Community First Choice

If you live in a CFC state, contact your local Medicaid office to ask about the application process. You can find your local Medicaid office here. If you don't live in a CFC state, you can still contact your local Medicaid office to find out whether there are any other home- and community-based programs for which you might be eligible.

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