Community First Choice
Purpose: To explain the Community First Choice (CFC) program that provides long-term services and supports (LTSS). CFC is for people living outside of a medical institution, who are eligible for categorically needy (CN) or alternate benefit plan (ABP) scope of care through Medicaid, and who meet nursing facility level of care (NFLOC) or the criteria to reside in an Intermediate Care Facility for the Intellectually Disabled (ICF/ID). CFC starts 7/1/2015
Functional eligibility is based on a CARE assessment under Chapter 388-106 WAC and 388-828 WAC and can be authorized by Home and Community Services (HCS) or Developmental Disabilities Administration (DDA).
The department authorizes CFC for a person who meets both:
- Institutional level of care based on the assessment by HCS or DDA case manager or HCS social worker; and
- Financial eligibility for a CN or ABP Medicaid program, including receiving CN through a HCB waiver. A person may receive both CFC and HCB waiver services at the same time.
Which community settings are used for CFC?
CFC can be authorized in a:
- Person's home; or
- HCS or DDA contracted alternate living facilities (ALF) contracted for CFC services.
What is the resource limit for CFC?
The resource limit is based on the CN or ABP program rules that the client is receiving:
- For people eligible under the MAGI-based programs through the Health Benefit Exchange there is no resource limit;
- For people eligible under Apple Health for Workers with Disabilities (HWD) there is no resource limit;
- For people eligible under SSI-related programs;
- The single person resource limit is $2,000
- The married couple resource limit is $3,000
- The married couple resource limit using spousal impoverishment is $2,000 for the recipient and $54,726 for the community spouse beginning July 1, 2015. See resource standards.
The resource standard is found on the Standards - LTC page.
Do transfer penalties apply to CFC?
Transfer penalties do not apply to people who only receive CFC. Transfer penalties do apply to home and community based (HCB) waivers described in chapter 182-515 WAC. If a person needs CFC in combination with HCB waiver services, transfer penalty rules described in WAC 182-513-1363 apply.
Does the home equity limit apply to CFC?
The home equity limit described in WAC 182-513-1350 applies to CFC because it is considered "Long-Term care" under the Social Security Act
How does the eligibility process work?
If the client is not eligible for MAGI we need to consider eligibility for a classic Medicaid program under one of the groups listed below.
|CFC Eligibility Only (L52*)|
|Group A||2-person CNIL (married plus deemed income)||
$3,000 (married living together)
$2,000 (all other)
|Regular S02 rules|
|Group B||1-person CNIL||State CSRA||With community Spouse (CS)|
|Group C||SIL and state rate plus $38.84||$2,000||Not income eligible in Group A, lives in a contracted ALF|
|Group D||SIL and state rate plus $38.84||state CSRA||With CS, not resource eligible in Group C|
|HCB Waiver plus CFC or HCB Waiver Eligibility (L22/L32* / L42*)|
|Group 1||Otherwise eligible using Group A||$2,000 (single) state CSRA with (CS)||HCS & DDA|
|Group 2||Not Group A, but < SIL||$2,000 (single) state CSRA (with CS)||HCS & DDA|
|Group 3||Not Group 2, but < Effective MNIL||$2,000 (single) state CSRA (with CS)||HCS Only (no hospice only)|
If a client is disabled and under 65 with earnings and not eligible under group A or group B, check to see if HWD is a better option than group C or D or under HCB waiver rules. A person can receive CFC under the HWD program.
Do clients pay participation on CFC services?
Clients living at home and only receiving CFC will have no participation.
If a CFC eligible person lives in an ALF:
- And is eligible under Group A or Group B, this person keeps their personal needs allowance (PNA) and pays up to the Room and Board standard.
- And is eligible under Group C or Group D, the person keeps their PNA, pays Room and Board, and pays the remainder of their income to their provider. This total amount is called "total client responsibility"
Clients receiving CFC and waiver pay participation for both CFC and waiver services depending on setting and which administration approves the services (DDA/HCS).
Which programs are not eligible for CFC?
Title XXI Children's Health Insurance Program (CHIP) because it is not a Title XIX Apple Health program.
Alien emergency medical (AEM)
Medical care services (MCS)
Program of all-inclusive care for the elderly (PACE)
Roads to community living (RCL)
Medically needy (MN)
Does spousal impoverishment apply to CFC?
If otherwise eligible under group A, group C or Healthcare for Workers with Disabilities (HWD), there is no need for spousal impoverishment protections. However, if not eligible under group A or group C due to spousal deeming or resources; or if not eligible under HWD due to spousal income, we can use spousal impoverishment protections.
If an SSI-related married person is found functionally eligible for CFC, and their spouse isn’t in a medical institution, the CFC eligible person can use the financial benefits of spousal impoverishment protections in eligibility. Spousal impoverishment applies to SSI-related non-institutional Medicaid when there is a SIPC spouse. Even using spousal impoverishment, the client applying for CFC must meet the following:
- Countable income in the name of the CFC eligible person must be at or below the standard for group B, group D, or HWD; and
- Combined resources must be at or below the state resource standard, plus $2,000 (Resources do not apply to HWD).
When we apply spousal impoverishment to CFC does it work the same as spousal impoverishment for HCB waiver?
Yes. When a client is on CFC only and is married, spousal impoverishment rules, described in WAC 182-513-1220 (for CFC), apply just like WACs 182-513-1350, 182-515-1509, and 182-515-1514 (for waiver). However, since a CFC only person doesn’t participate, post eligibility protections do not apply.
Even though spousal impoverishment rules apply to the G03 program, there is no post eligibility spousal or dependent allocation, because there is no "participation" under the G03 program. Clients must still pay room and board and their remaining income towards total client responsibility.
Spousal impoverishment doesn't apply to modified adjusted gross income (MAGI) clients.
Can a client receive both CFC and waiver services? What about hospice?
Yes. Clients can receive CFC, waiver and hospice at the same time. Waiver will be the priority program, CFC and hospice will be services. The programs will all be identified on the INST screen in ACES mainframe or Institutional Care in ACES 3G.
Are full benefit dual eligible (FBDE) recipients who receive CFC-only exempt from Medicare Part D copayments in the same way as HCB waiver recipients?
No. Under the Low Income Subsidy (LIS) Program, dual eligible clients who receive CFC-only will not be LIS 3 (like HCB waiver and institutional clients), and are subject to Medicare Part D copayments.
If a client has high Medicare Part D costs, financial staff should coordinate with social services to move the client to a HCB waiver if possible.
What if someone on CFC needs a service only available under a waiver?
If a client is on CFC only, and needs a waiver service, financial staff will receive a communication from either the HCS social worker 14-443 or DDA case manager 15-345 informing of the change. The client will remain on the waiver until their next annual assessment or significant change.
For CFC only, if the client is active on SSI-related CN medical a program change is needed. The social worker/case manager will notify the financial worker of the start date and type of service via the 14-443 or 15-345. The financial worker will indicate CFC. This information is coded on the institutional care tab in ACES 3G or INST screen in ACES mainframe. This AU will be managed by DDA or HCS financial worker.
For clients not on Medicaid who are under age 65 and not on medicare, a MAGI determination through the Healthplanfinder needs to be made first.
For clients who need classic Medicaid, determine eligibility under groups A, B, C, or D. Follow eligibility requirements for Medicaid.
If the client is not eligible under groups A, B, C, or D, determine eligibility under HCB waiver rules . The financial worker will need to notify the social worker or case manager using the barcode 07-104, indicating that HCB waiver rules are needed for CN eligibility. If DDA is unable to authorize services under a waiver, send a 07-104 to HCS intake for an HCS waiver assessment.