4100, Community First Choice

Revision 22-3; Effective Dc. 1, 2022

Community First Choice (CFC) is a group of services delivered under the authority of Section 1915(k) of the Social Security Act. CFC is authorized by federal regulations governing home and community-based services. The settings that CFC is delivered must be compliant with Title 42 Code of Federal Regulations (CFR) Section 441.301(c)(4) and Section 441.710. Permissible home and community-based settings include member homes, apartment buildings and non-residential settings. Community-based settings exclude:

  • nursing facilities;
  • hospitals providing long-term care services;
  • inpatient psychiatric facilities;
  • intermediate care facilities for individuals with an intellectual disability or related conditions (ICF/IID); and
  • settings on the grounds of, adjacent to, or with the characteristics of, an institution.

Members served in provider owned and controlled residential settings are excluded from CFC because their provider rate includes payment for the provision of CFC-like services. To provide CFC is duplicative.

In addition, assessment for CFC services and the development of a member's service plan must be person centered, as required by 42 CFR Section 441.535 and Section 441.540. STAR Kids managed care organizations may not require CFC providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for CFC services.

4110 Community First Choice Eligibility

Revision 22-3; Effective Dc. 1, 2022

Eligibility for Community First Choice (CFC) requires a STAR Kids member to:

  • be Medicaid eligible;
  • meet the level of care provided in a hospital, nursing facility (NF), intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), or an institution for mental disease (IMD); and
  • have an assessed functional need for CFC services.

All STAR Kids members are Medicaid eligible. Members whose Medicaid eligibility is established for the Youth Empowerment Services (YES) or Medically Dependent Children Program (MDCP) waivers are eligible for CFC services, per Section 1902(a)(10)(A)(ii)(VI) of the Social Security Act, as long as they receive at least one waiver service per month or monthly monitoring if waiver services are furnished on a less than monthly basis, as these members meet an IMD and an NF LOC, respectively. Members whose eligibility is established as Medical Assistance Only (MAO) Medicaid must receive at least one waiver service per month to maintain eligibility. 

A member may not be authorized to receive both personal care services (PCS) and CFC services at the same time. Members eligible for CFC will receive CFC-PCS and habilitation (CFC-HAB) in lieu of PCS.

Members who receive services through the following 1915(c) waiver programs receive CFC services through their fee-for-service waiver provider and do not receive CFC through managed care:

  • Community Living Assistance and Support Services (CLASS)
  • Deaf Blind with Multiple Disabilities (DBMD)
  • Home and Community-based Services (HCS)
  • Texas Home Living (TxHmL)
     

4111 Determining Institutional Level of Care

Revision 22-3; Effective Dc. 1, 2022

Nursing Facility (NF) Level of Care

For STAR Kids members, the STAR Kids Screening and Assessment Instrument (SK-SAI) contains the elements necessary for Texas Medicaid & Healthcare Partnership (TMHP) to determine, on behalf of the Texas Health and Human Services Commission (HHSC), if a member meets medical necessity (MN) for the level of care (LOC) provided in a hospital or NF. Questions within the SK-SAI which identify a need for Community First Choice (CFC) personal assistance services (PAS)/habilitation (HAB) services are within the Core  and Nursing Care Assessment (NCAM) modules of the SK-SAI. Once the SK-SAI is completed, if the STAR Kids managed care organization (MCO) seeks a determination of MN for CFC, the MCO must obtain the member's physician's signature on Form 2601, Physician Certification, certifying the member requires NF services or alternative community based services under the supervision of a physician.

Find information about the medical necessity determination process for CFC in 3110, Assessment of Medical Necessity for Community First Choice.

Intermediate Care Facility for Individuals with an Intellectual Disability or Related Condition (ICF/IID) Level of Care

For STAR Kids applicants and members, the MCO must contact the Local Intellectual and Developmental Disability Authority (LIDDA) to conduct an assessment to determine whether a STAR Kids applicant or member meets the LOC provided by an ICF/IID. As part of the Intellectual Disability or Related Condition (ID/RC) assessment, the LIDDA must collect information necessary to complete a Determination of Intellectual Disability (DID), if a STAR Kids applicant or member does not have one on file. The LIDDA must submit the ID/RC information to HHSC for a determination of ICF-IID LOC. HHSC notifies the STAR Kids applicant or member's MCO of an ICF/IID LOC denial. The LIDDA notifies the STAR Kids applicant or member’s MCO of an ICF/IDD LOC approval. If a STAR Kids applicant or member meets the LOC provided in an ICF/IID, the MCO completes the CFC functional assessment if the applicant or member requests CFC services.

Institution for Mental Disease Level of Care

For STAR Kids applicants and members, the MCO may contact a comprehensive provider of mental health rehabilitative services or a local mental health authority (LMHA) to conduct the Children and Adolescent Needs and Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA) and a licensed practitioner determines whether the STAR Kids applicant or member meets an institution of mental disease (IMD) LOC. If the STAR Kids applicant or member needs the LOC provided in an IMD, or receives services through the Youth Empowerment Services program, the MCO conducts the CFC functional assessment if the member requests CFC services.

4120 Community First Choice Services

Revision 22-2; Effective September 1, 2022

Community First Choice (CFC) services include personal care services (PCS), habilitation (HAB), emergency response services (ERS) and support management.

4121 Personal Care Services Provided Through Community First Choice

Revision 22-3; Effective Dec. 1, 2022

Community First Choice (CFC) includes personal care services (PCS) which provide assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) through hands-on assistance, supervision or cueing. Assistance is provided to a member in performing ADLs and IADLs based on a person-centered service plan. Services include:

  • Non-skilled assistance with the performance of ADLs and IADLs
  • Household chores necessary to maintain the home in a clean, sanitary and safe environment
  • Escort services, which consist of accompanying, but not transporting, and helping a member access services or activities in the community 
  • Assistance with health-related tasks per state law, health-related tasks include: 
    • tasks delegated by a registered nurse (RN);
    • health maintenance activities; and 
    • extension of therapy which is an activity that a speech therapist, physical therapist or occupational therapist instructs the member to do as follow up to therapy sessions. If appropriate, the member's attendant can help the member accomplish such activities with supervision, cueing and hands-on assistance.

In the Consumer Directed Services (CDS) service delivery option, the member or legally authorized representative determines health-related tasks without a nurse assessment, per Section 531.051(e) of the Texas Government Code and Section 225.4 of the Texas Administrative Code.

CFC services include personal care services (PCS) to help with ADLs, IADLs, and health-related tasks through hands-on assistance, supervision or cueing, including nurse-delegated tasks.  Members who qualify for a CFC LOC must have PCS billed as CFC-PCS. Members may not be authorized for PCS and CFC-PCS at the same time. Information used to build a plan of care  may be found in the STAR Kids Screening and Assessment Instrument (SK-SAI) Sections I-L. The member may receive CFC-PCS and CFC-HAB only if the member meets one of the CFC LOC criteria.

4122 Community First Choice Habilitation

Revision 22-3; Effective Dec. 1, 2022

Community First Choice (CFC) habilitation helps members with acquisition, maintenance and enhancement of skills necessary for the member to accomplish activities of daily living (ADLS), instrumental activities of daily living (IADLs) and health-related tasks. This service is given to allow a member to live successfully in a community setting by assisting the member to get, keep and improve self-help, socialization, and daily living skills or helping with and training the member on ADLs and IADLs. Personal care services may be a component of CFC habilitation for some members. CFC habilitation services include training, which is interacting face-to-face with a member to train the member in activities such as:

  • self-care;
  • personal hygiene;
  • household tasks;
  • mobility;
  • money management;
  • community integration, including how to get around in the community;
  • use of adaptive equipment;
  • personal decision-making;
  • reduction of challenging behaviors to allow members to accomplish ADLs, IADLs and health-related tasks; and
  • self-administration of medication.

Find information used to build a plan of care for CFC habilitation in the STAR Kids Screening and Assessment Instrument (SK-SAI) Section M. This section of the SK-SAI should only be administered after the assessor or service coordinator explains the CFC benefit and the member wishes to be assessed for habilitation.

4123 Community First Choice Emergency Response Service

Revision 22-2; Effective September 1, 2022

Community First Choice (CFC) emergency response services (ERS) are designed to assist individuals who live alone, are alone for large parts of the day, or have no regular caregiver for extended periods of time and who would otherwise require extensive routine supervision. This service connects a member to an ERS provider who notifies local authorities, like paramedics or a fire department, of a member's emergency. This service is not routinely authorized for members who are minors.

ERS provides backup systems and supports to ensure continuity of services and supports. Reimbursement for backup systems and supports is limited to electronic devices to ensure continuity of services and supports. A member must be cognitively able to recognize an emergency situation and be able to recognize the need to use CFC-ERS for CFC-ERS to be authorized.

The need for ERS is assessed using the STAR Kids Screening and Assessment Instrument (SK-SAI), Section Q.

4124 Community First Choice Support Management

Revision 22-2; Effective September 1, 2022

Community First Choice (CFC) support management provides voluntary training on how to select, manage and dismiss attendants. Support management is available to any member receiving CFC services, regardless of the selected service delivery model.

Need for support management is assessed using the STAR Kids Screening and Assessment Instrument, Section Q.

4130 Community First Choice Assessment and Authorization

Revision 22-3; Effective Dec. 1, 2022

4131 Assessment for a Nursing Facility Level of Care

Revision 22-3; Effective Dec. 1, 2022

Establish nursing facility level of care (LOC) for members seeking Community First Choice (CFC) services using the STAR Kids Screening and Assessment Instrument (SK-SAI). The managed care organization (MCO) must complete all "MN required" fields, as specified in Appendix I, MCO Business Rules for SK-SAI and SK-ISP, particularly items contained in the Nursing Care Assessment Module (NCAM). These items will be used by a Texas Medicaid & Healthcare Partnership (TMHP) nurse to evaluate the member's eligibility for NF services according to the Texas Administrative Code Section 554.101(80) definition of “medical necessity.”

The MCO must indicate yes in Field Q6a to notify TMHP that an MN determination is required. TMHP's determination will be communicated to the MCO on the substantive response file, as specified in Appendix I.

If TMHP determines that the member does not meet MN, the member is not eligible to receive CFC through the nursing facility LOC. Note: This does not preclude the member or MCO from seeking determination of a different institutional LOC through the LIDDA or LMHA.

If TMHP determines that that the member meets MN and the functional assessment conducted by the MCO indicates a need for CFC services, the member is eligible to receive CFC through the nursing facility LOC.

4132 Reassessment for a Nursing Facility Level of Care

Revision 22-2; Effective September 1, 2022

To ensure continued eligibility for Community First Choice (CFC) services, the managed care organization (MCO) administers the entire STAR Kids Screening and Assessment Instrument (SK-SAI), including appropriate modules, no earlier than 90 Days before or no later than 30 days prior to the expiration of the member’s current individual service plan (ISP) on file. The MCO must indicate yes in Field Q6a to notify Texas Medicaid & Healthcare Partnership (TMHP) that a medical necessity (MN) determination is required. Form 2601, Physician Certification, is not required for annual MN reassessments if the member's file contains the form for a previous assessment. The MCO must ensure that the reassessment is timed to prevent any lapse in service authorization.

4133 Assessment for an Intermediate Care Facility Level of Care

Revision 22-3; Effective Dec. 1, 2022

Described in Section 4111, Determining Institutional Level of Care, if the managed care organization (MCO) knows or believes a member has an intellectual disability or related condition (ID/RC), the MCO refers the member to the Local Intellectual and Developmental Disability Authority (LIDDA). The MCO must authorize personal care services (PCS), as appropriate, while level of care (LOC) determination is pending. 

The LIDDA and the MCO communicate during the assessment process through a Secure File Transfer Protocol (SFTP) site, updating the file as the member moves through the assessment process. The MCO initiates a referral to the LIDDA by adding a referred member to the spreadsheet. The MCO must provide the member's named service coordinator’s contact information to assist in coordinating assessment activities. Following completion of the determination of intellectual disability (DID) and ID/RC assessment, the LIDDA submits the assessment for a determination of LOC to the state. The Texas Health and Human Services Commission (HHSC) informs both the LIDDA and MCO of the determination. If a member is determined to not meet the level of care provided in an intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID), the MCO is responsible for notifying the member through the established denial process. HHSC attends the fair hearing if one is requested.

If a member meets an ICF/IID level of care, the MCO follows the process outlined in Section 4140, Functional Assessment for Community First Choice Services, to determine the member's service plan. When the member selects a service provider, the MCO updates the SFTP site noting the member's selected provider. If a member declines or discontinues Community First Choice services, the MCO must update the SFTP site noting the date the member declined or discontinued services.

4134 Reassessment for an Intermediate Care Facility Level of Care

Revision 22-3; Effective Dec. 1, 2022

Ninety days before the expiration of the member's level of care assessment, the Local Intellectual and Development Disability Authority (LIDDA) updates the Secure File Transfer Protocol (SFTP) site requesting the managed care organization (MCO) confirm the member requires a reassessment of an intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID) level of care. If a member is receiving Community First Choice (CFC) services, the MCO indicates the member requires a reassessment. If the member declined or discontinued CFC services, the MCO indicates the member does not require a reassessment. The LIDDA and the MCO follow the processes outlined in Section 4132, Assessment for an ICF/IID Level of Care, for all reassessments.

If a member continues to meet an ICF/IID level of care, the MCO follows the process outlined in Section 4140, Functional Assessment for CFC Services, to determine the member's service plan. When the member selects a service provider, the MCO updates the SFTP site noting the member's selected provider. If a member declines or discontinues CFC services, the MCO must update the SFTP site noting the date the member declined or discontinued services.

4135 Assessment for an Institution Providing Psychiatric Services Level of Care

Revision 22-2; Effective September 1, 2022

Described in 4111, Determining Institutional Level of Care, if the managed care organization (MCO) knows or believes a member has serious emotional disturbance (SED) or serious and persistent mental illness (SPMI), the MCO refers the member to a comprehensive provider agency that can deliver mental health targeted case management and mental health rehabilitative services. This provider conducts the Child and Adolescent Needs or Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA), depending on the member's age. Based on an algorithm, the assessment determines the member's level of care (LOC). A member may be deviated into a higher or lower LOC, based on clinical judgement and member preference. A licensed practitioner of the healing arts (LPHA) must review the member’s diagnosis at least annually. Mental health rehabilitative services are reassessed more frequently than the LOC for Community First Choice (CFC) services. For the purposes of eligibility for CFC services, a member's CANS or ANSA is valid for 12 months. The MCO must authorize personal care services (PCS), as appropriate, while LOC determination is pending.

Members enrolled in the Youth Empowerment Services (YES) waiver meet an institution for mental disease level of care and do not require an additional assessment of LOC to receive CFC services. These members may be assessed by their MCO for functional eligibility for CFC services at any time while enrolled in YES. 

4136 Reassessment for an Institution for Mental Disease Level of Care

Revision 22-2; Effective September 1, 2022

Assessment of an institution for mental disease (IMD) level of care (LOC) must be reassessed annually for continued eligibility for Community First Choice (CFC) services. Sixty days prior to the expiration of the member's CFC service plan, the managed care organization (MCO) must refer the member to the local mental health authority (LMHA) or to a comprehensive provider for mental health rehabilitative services. This provider conducts the Child and Adolescent Needs or Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA), which must be reviewed by a licensed practitioner to determine if the member continues to meet a psychiatric institutional LOC. If the member continues to meet this LOC, the MCO conducts the CFC functional assessment.

If the member does not meet an IMD level of care, the MCO must conduct the STAR Kids Screening and Assessment Instrument (SK-SAI) to determine if the member meets medical necessity for a nursing facility LOC. If the MCO believes the member will not meet medical necessity and does not have an intellectual or developmental disability, the MCO must notify the member or their representative of the denial for CFC services. The member may be eligible for personal care services (PCS), if functionally necessary.

4140 Functional Assessment for Community First Choice Services

Revision 22-3; Effective Dec. 1, 2022

Functional need for Community First Choice (CFC) services is established by Sections I, J, K, L and M of the STAR Kids Screening and Assessment Instrument (SK-SAI). These sections contain assessment questions for the personal care services (CFC-PCS) and habilitation services (CFC-HAB) available through CFC. Section M should only be completed if the member is specifically seeking CFC services. Based on the assessment, the service coordinator develops a recommended service plan for the delivery of CFC services. The service coordinator works with the member or their representative to locate an appropriate provider and sends an authorization to the selected provider.

If a member approved for the nursing facility (NF) level of care (LOC) does not agree to the CFC service plan, they may file an appeal with the MCO.

If the STAR Kids applicant or member does not agree to the CFC service plan or refuses CFC services for the intermediate care facility for individuals with intellectual disability or related condition (ICF/IID) LOC or the institutions of mental disease (IMD) LOC, the MCO must notify the local intellectual or developmental disability authority (LIDDA) or local mental health authority (LMHA) within 10 business days of the member ending CFC services.

4141 Reassessment of Functional Need for Community First Choice

Revision 22-2; Effective September 1, 2022

The need for and the amount and duration of Community First Choice services must be reassessed every 12 months, or when requested by the member or as needed due to a change in the member's health condition or living situation.