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


The Affordable Care Act added §1915(k) to the Social Security Act to allow states to provide “Community-based Attendant Services and Supports”--called the Community First Choice Option--effective October 2011. Under §1915(k), states that provide home and community-based attendant services and supports through their State Plans will receive a six percentage points higher Federal match. To be eligible for this benefit, individuals must meet Medicaid State Plan eligibility criteria and have incomes that do not exceed 150 percent of the federal poverty level. If their income is greater, they must meet institutional level-of-care criteria.

Services under this option include home and community-based attendant services for the purpose of assisting in “accomplishing activities of daily living, instrumental activities of daily living, and health-related tasks through hands on assistance, supervision, or cueing.” Funds can also be spent to provide assistance with “the acquisition, maintenance, and enhancement of skills necessary” for the individual to accomplish such tasks; for “back-up systems or mechanisms to ensure continuity of services and supports (such as the use of beepers or other electronic devices)”; and for ‘‘voluntary training on how to select, manage, and dismiss attendants.”

This option can also fund transition expenses incurred when moving from an institution to the community, such as security deposits for an apartment or utilities, as well as basic kitchen supplies, bedding, and other necessities required for transition. The law also allows “expenditures relating to a need identified in an individual’s person-centered service plan that increase independence or substitute for human assistance, to the extent that expenditures would otherwise be made for the human assistance.”

Specific requirements for states that provide these services and supports include the following:

  • Collaborate with a Development and Implementation Council established by the state that includes a majority of members with disabilities, elderly individuals, and their representatives.

  • Establish and maintain a comprehensive continuous quality assurance system specifically for this service.

  • Collect and report information for Federal oversight and the completion of a Federal evaluation of the program.

For the first full fiscal year in which the State Plan amendment is implemented, the state must maintain or exceed the level of expenditures for services provided under the State Plan, waiver programs, or demonstrations.

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