Long-term services and supports (LTSS) manual

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Community First Choice

Revised Date: 
July 1, 2015

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).

WAC 182-513-1210  Community First Choice (CFC) – Overview

Emergency effective February 20, 2017

  1. ​Community first choice (CFC) is a Washington apple health state plan benefit authorized under Section 1915(k) of the Social Security Act.
  2. CFC enables the agency and its contracted entities to deliver person-centered home and community based long-term services and supports (LTSS) to medicaid-eligible people who meet the institutional level of care under WAC 388-106-0355. See:
    1. WAC 388-106-0270 through 388-106-0295 for services included within the CFC benefit package.
    2. WAC 182-513-1215 for financial eligibility for CFC services.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-513-1215 Community First Choice (CFC) – Eligibility

Effective May 30, 2021

  1. A client who is determined functionally eligible for community first choice (CFC) services under WAC 388-106-0270 through 388-106-0295 is financially eligible to receive CFC services if the client is:
    1. Eligible for a noninstitutional Washington apple health (medicaid) program which provides categorically needy (CN) or alternative benefits plan (ABP) scope of care;
    2. Through September 30, 2023, a spousal impoverishment protections institutional (SIPI) spouse under WAC 182-513-1220; or
    3. Determined eligible for a home and community based (HCB) waiver program under chapter 182-515 WAC.
  2. A client whose only coverage is through one of the following programs is not eligible for CFC:
    1. Medically needy program under WAC 182-519-0100;
    2. Premium-based children's program under WAC 182-505-0215;
    3. Medicare savings programs under WAC 182-517-0300;
    4. Family planning program under WAC 182-505-0115;
    5. Take charge program under WAC 182-532-0720;
    6. Medical care services program under WAC 182-508-0005;
    7. Pregnant minor program under WAC 182-505-0117;
    8. Alien emergency medical program under WAC 182-507-0110 through 182-507-0120;
    9. State-funded long-term care (LTC) for noncitizens program under WAC 182-507-0125; or
    10. Kidney disease program under chapter 182-540 WAC.
  3. Transfer of asset penalties under WAC 182-513-1363 do not apply to CFC applicants, unless the client is applying for long-term services and supports (LTSS) that are available only through one of the HCB waivers under chapter 182-515 WAC.
  4. Home equity limits under WAC 182-513-1350 do apply.
  5. Post-eligibility treatment of income rules do not apply if the client is eligible under subsection (1)(a) or (b) of this section.
  6. Clients eligible under subsection (1) (a) or (b) of this section, who reside in an alternate living facility (ALF):
    1. Keep a personal needs allowance (PNA) under WAC 182-513-1105; and
    2. Pay up to the room and board standard under WAC 182-513-1105 except when CN eligibility is based on the rules under WAC 182-513-1205.
  7. A client who receives CFC services under the health care for workers with disabilities (HWD) program under chapter 182-511 WAC must pay the HWD premium in addition to room and board under WAC 182-513-1105, if residing in an ALF.
  8.  Post-eligibility treatment of income rules do apply if a client is eligible under subsection (1)(c) of this section.
  9.  A client may have to pay third-party resources as defined under WAC 182-513-1100 in addition to the room and board and participation.
  10. PNA, MNIL, and room and board standards are found at www.hca.wa.gov/health-care-services-supports/program-standard-income-and-resources.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-513-1220 Community First Choice (CFC) - Spousal impoverishment protections for noninstitutional Washington Apple Health clients.

Effective May 30, 2021

  1. This section is effective through September 30, 2023.
  2. The agency or its designee determines eligibility for community first choice (CFC) using spousal impoverishment protections under this section, when an applicant:
    1. Is married to, or marries, a person not in a medical institution;
    2. Meets institutional level of care and eligibility for CFC services under WAC 388-106-0270 through 388-106-0295;
    3. Is ineligible for a noninstitutional categorically needy (CN) SSI-related program:
      1. Due to spousal deeming rules under WAC 182-512-0920, or due to exceeding the resource limit in WAC 182-512-0010, or both; or
      2. In an ALF due to combined spousal resources exceeding the resource limit in WAC 182-512-0010; and
    4. Meets the aged, blindness, or disability criteria under WAC 182-512-0050.
  3. The agency or its designee determines countable income using the SSI-related income rules under chapter 182-512 WAC but uses only the applicant's or recipient's separate income and not the income of the applicant's or recipient's spouse.
  4. The agency or its designee determines countable resources using the SSI-related resource rules under chapter 182-512 WAC, except pension funds owned by the spousal impoverishment protections community (SIPC) spouse are not excluded as described under WAC 182-512-0550:
    1. For the applicant or recipient, the resource standard is $2000.
    2. Before determining countable resources used to establish eligibility for the applicant, the agency allocates the state spousal resource standard to the SIPC spouse.
    3. The resources of the SIPC spouse are unavailable to the spousal impoverishment protections institutionalized (SIPI) spouse the month after eligibility for CFC services is established unless subsection (9) of this section applies.
  5. The SIPI spouse has until the end of the month of the first regularly scheduled eligibility review to transfer countable resources in excess of $2000 to the SIPC spouse.
  6. A redetermination of the couple's resources under subsection (4) of this section is required if:
    1. The SIPI spouse has a break in CFC services of at least thirty consecutive days;
    2. The SIPI spouse's countable resources exceed the standard under subsection (4)(a) of this section; or
    3. The SIPI spouse does not transfer the amount under subsection (5) of this section to the SIPC spouse by the end of the month of the first regularly scheduled eligibility review.
  7. If the applicant lives at home and the applicant's separate countable income is at or below the SSI categorically needy income level (CNIL) and the applicant is resource eligible, the applicant is a SIPI spouse and is financially eligible for noninstitutional CN coverage and CFC services.
  8. If the applicant lives in an ALF, has separate countable income at or below the standard under WAC 182-513-1205(2), and is resource eligible, the applicant is a SIPI spouse and is financially eligible for noninstitutional CN coverage and CFC services.
  9. If the applicant is employed and has separate countable income at or below the standard under WAC 182-511-1060, the applicant is a SIPI spouse and is financially eligible for noninstitutional CN coverage and CFC services.
  10. Once a person no longer receives CFC services for thirty consecutive days, the agency redetermines eligibility without using spousal impoverishment protection, under WAC 182-504-0125.
  11. If the applicant's separate countable income is above the standards under subsections (7), (8), and (9) of this section, the applicant is not eligible for CFC services under this section.
  12. The spousal impoverishment protections under this section expire on September 30, 2023.
  13. Standards are found at http://www.hca.wa.gov/health-care-services-supports/program-standard-income-and-resources.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

The department authorizes CFC for a person who meets both:

  1. Institutional level of care based on the assessment by HCS or DDA case manager or HCS social worker; and
  2. 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:

  1. Person's home; or
  2. 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:

  1. For people eligible under the MAGI-based programs through the Health Benefit Exchange there is no resource limit;
  2. For people eligible under Apple Health for Workers with Disabilities (HWD) there is no resource limit;
  3. For people eligible under SSI-related programs;
    1. The single person resource limit is $2,000
    2. The married couple resource limit is $3,000
    3. 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 and LTSS 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 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.

Group Income Resources Notes
  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)
Coverage group Description
L52 CFC SSI-Related

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:

  1. 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.
  2. 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.

State-funded children

Alien emergency medical (AEM)

Medical care services (MCS)

Program of all-inclusive care for the elderly (PACE)

New freedom

Roads to community living (RCL)

Medically needy (MN)

Does spousal impoverishment apply to CFC?

If otherwise eligible under group A, group C or Health Care 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 noninstitutional Medicaid when there is a SIPC spouse. Even using spousal impoverishment, the client applying for CFC must meet the following:

  1. 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
  2. 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.

Worker Responsibilities

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 HCS Home and Community based (HCB) waivers . 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.