The Community First Choice (CFC) Option

The Community First Choice (CFC) Option emerged from discussions with Senator Harkin's (D-IA) and Representative Davis' (D-IL) offices in August of 2009 as a way to make progress on home and community-based services and supports under Medicaid and a way to lay the foundation for later enactment of the Community Choice Act. The CFC Option would encourage states to provide home and community based services by providing an increased federal share Medicaid of payments. However, if a state chooses the CFC option, they would have to adhere to its higher standards (no caps on services, no waiting lists, and no geographic restrictions.)

What Does an “Option” Mean?

Medicaid logoTo explain this, we need a very quick overview of how Medicaid works. In order to receive federal matching funds, states must abide by the federal Medicaid law. This law basically defines what states: 1) must do; 2) can choose to do (referred to as an “option”); and 3) cannot do. As long as states comply with the federal law, they are free to set their own guidelines regarding eligibility and services.

However, states can request to do other than that specified in the law by applying for a waiver. There are currently nearly 300 waivers in effect across the country.

States that wish to provide most services to people with disabilities in the community instead of institutional settings must apply for a Section 1915(c) Home and Community-Based Services (HCBS) Waiver. While most states have these kinds of waivers, there are problems with them as they allow states to limit eligibility and services.

Why Would the CFC Option be Better than the Current HCBS Waiver?

There are a number of reasons why the CFC option would be better for people with disabilities. The most important ones are outlined in the chart below comparing what states are allowed to do under each.

States allowed to:CFC OptionSection 1915(i) HCBS Waivers
Cap services NO YES
Have waiting lists NO YES
Limit services to certain sections of the state NO YES

The other very important benefit is that an HCBS option would provide the legitimacy and prominence that a waiver does not have. For the first time, HCBS would be on the list of what states can chose to do instead of the exception to that list. In other words, the option would help to expedite an end to Medicaid’s institutional bias.

Would the CFC Option Replace the HCBS Waiver?

No. The 1915(c) waiver will still be allowed. States would simply be allowed to choose the CFC option. However, if a state chooses the CFC option, they would have to adhere to its higher standards (no caps on services, no waiting lists, no geographic restrictions.)

What are the CFC Option's Core Provisions?

  • Make community-based services a state option. Medicaid Law will be amended to allow state Medicaid plan coverage of community-based attendant services and supports for certain Medicaid-eligible individuals.
  • Specify that the services under this option would include assistance with:
    * Activities of daily living (ADLs). These include eating, toileting, grooming, dressing, bathing, and transferring.
    * Instrumental activities of daily living (IADLs). These include meal planning and preparation; managing finances; shopping for food, clothing, and other essential items; performing essential household chores; communicating by phone and other media; and traveling around and participating in the community.
    * Health-related tasks. Health-related tasks are defined as those tasks that can be delegated or assigned by licensed health-care professionals under state law.
  • Specify that services would be performed by an attendant through hands-on assistance, supervision, or cueing.
  • Specify that services would also include assistance in learning the skills necessary for the individual to accomplish these tasks him/herself; back-up systems; and voluntary training on selection and management of attendants.
  • Exclude certain expenditures, including room and board; services provided under IDEA and the Rehabilitation Act; assistive technology devices and services; durable medical equipment; and home modifications.
  • Require that there be a written plan for home and community based services.
  • Require that services are made available statewide and that they be provided in the most integrated setting appropriate for the individual.
  • Require services to be provided regardless of age, disability, or type of services needed.
  • Require states to establish and maintain a comprehensive, continuous quality assurance system.
  • Require service delivery models to include consumer directed, agency-based, and other models, and require states to comply with all federal and state labor laws.
  • Require states to establish a Development and Implementation Council, the majority of whose members must be individuals with disabilities, elderly individuals, and their representatives.
  • Require states to report to Congress.
  • Prohibit CFC services from affecting the states’ ability to provide such services under other Medicaid provisions.

For the detailed provisions of the CFC option, see Section 2401 of the Affordable Care Act (ACA).

What Incentives are there for States to Use the CFC Option?

The federal government would provide more funding to states that use it. The CFC option provides a 6% increase in the federal medical assistance percentage (FMAP) for home and community based services.

How Many States are Likely to Use the CFC Option?

There is no way to know at this point. Now that health care reform has been signed into law, advocates will need to work hard to encourage their states to use the option.

It is worth noting, however, that some states already provide community based services only and serve people with disabilities well despite the low bar set by the 1915(c) waiver. In Vermont, for example, all Medicaid funding goes toward community-based housing and everyone lives in homes with fewer than seven people. Learn more about how state Medicaid HCBS programs rank in UCP’s report, A Case for Inclusion 2010.”

Why Make HCBS Just an Option, Why Not Require States to Provide Them?

The cost estimates for a mandatory CCA program are, in the opinion of Congressional leaders, prohibitive.

How Would the CFC Option Help to Get the CCA Enacted?

Since it was first introduced a decade ago as the Medicaid Community-Based Attendant Services and Supports Act (MiCASSA), the CCA has been hampered by conflicting analyses on the costs of providing community based services instead of institutional care. Having states that chose the CFC option serve as successful test cases could ease the concerns of Members of Congress, governors, and state legislators, among others.

How was The Arc involved in getting CFC Option inlcuded in the Health Care Reform Law?

The Arc's Marty Ford with President Obama and Attorney General HolderOn July 24, 2009 President Obama met with twelve representatives of the disability community, along with Attorney General Holder and Secretary of Labor Solis. Marty Ford participated in the meeting representing The Arc as well as the Consortium for Citizens with Disabilities. A broad range of issues were addressed, including Olmstead enforcement, health care reform, and the need to end the institutional bias in Medicaid.

On August 27, 2009 as a follow-up to the meeting with President Obama and his cabinet heads, a group of advocates for home and community-based long-term services and supports met with Nancy-Ann DeParle, Counselor to the President and Director of the White House Office of Health Reform, and other senior staff at the White House to discuss the Community First Choice Option. The meeting participants had a frank and productive discussion concerning the possible opportunities and barriers of including CFC Option in the final health reform legislation. Once the support of the Administration and several key Members of Congress was obtained, The Arc engaged its grassroots network in helping to ensure enactment.