Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. 5. State Plan Community First Choice Option


Section 2401 of the Affordable Care Act amends §1915 of the Social Security Act by adding a new subsection (k), effective October 2011, to allow states to provide “Community-based Attendant Services and Supports”--called the Community First Choice Option.

Under this new benefit, services and supports may be provided through an agency-provider model or “other” model, both of which require that participants or their representatives select, manage, and dismiss workers. An “other” model is defined as methods, other than an agency-provider model, for the provision of consumer-controlled services and supports. Such models may include the provision of vouchers, direct cash payments, or the use of a fiscal agent to assist in obtaining services, as long as the model allows for the services to be “selected, managed, and dismissed by the individual, or, as appropriate, with assistance from the individual’s representative,” and to be “controlled, to the maximum extent possible, by the individual…regardless of who may act as the employer of record.” Services must be provided by qualified individuals, although the law allows providers to be “family members,” and gives the Secretary of HHS latitude to define the term.

Employers must adhere to the provisions of the Fair Labor Standards Act of 1938 and applicable Federal and state laws regarding income and payroll taxes, unemployment and workers compensation insurance, general liability insurance, and occupational health and safety.

Key Participant Direction Features of the §1915(k) Authority

The authority has the following major features:

  • Use of a Representative. Participants may appoint a representative to direct services.

  • Service Plan. The state must fashion a person-centered service planning process based on a functional needs assessment.

  • Purchase of Non-Traditional Goods and Services. In addition to assistance with Activities of Daily Living and Instrumental Activities of Daily Living, permissible services may include… “the use of beepers or other electronic devices” and “voluntary training on how to select, manage, and dismiss attendants.” Expenditures for transition costs involved in moving from an institution to the community, including deposits for the first month’s payment for rent and utilities, bedding, basic kitchen supplies, and other necessities, can also be funded through this authority. The authority also allows “expenditures relating to a need identified in an individual’s person-centered plan of services that increase independence or substitute for human assistance, to the extent that expenditures would otherwise be made for the human assistance.”

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