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Community First Choice Option

HCBS Authority: 
Applicable CFR Sections: 
42 CFR §441.530-590

Provides a State plan option to provide consumer controlled home and community-based attendant services and supports

Provides a 6% FMAP increase for this option.

Medicaid Requirements That May Be Waived: 

Community income rules for medically needy population

Application Process: 

State plan amendment submitted on pre-print.

Preprint can be obtained from CMS Regional Offices

Approval Duration: 

One-time approval. Changes must be submitted to CMS and approved.


42 CFR §441.580: Data Collection

Annual data to include:

  • Number estimated to have received services broken down by type of disability, age, gender, education level, and employment status.
  • Cost data on providing CFC and other HCBS services and supports.
  • Data regarding how the State provides choice of CFC or institutional care.
  • Data regarding the impact of CFC on the physical and emotional health of individuals.
  • Other data as determined by the Secretary.
Administration & Operation: 

Administered by the Single State Medicaid Agency (SSMA).

Provider Agreements: 

Required between providers and the SSMA.

Medicaid Eligibility: 

Individuals eligible for Medicaid under the State plan up to 150% of Federal Poverty Level.

Individuals with income greater than 150% of the FPL may use the institutional deeming rules.

Other Eligibility Criteria: 

Must meet institutional level of care.

May include the special income group and receiving at least one §1915(c) HCBS waiver service per month.

Individuals receiving any CFC services must reside in CMS approved allowable HCB settings as per 42 CFR §441.530

Public Input: 

Must create a Development and Implementation Council that includes a majority of members with disabilities, elderly individuals, and their representatives. State must consult and collaborate with the Council when developing and implementing a State Plan amendment to provide HCBS attendant services.

Target Groups: 

No targeting. Services must be provided on a statewide basis, in a manner that provides such services and supports in the most integrated setting appropriate to the individual’s needs, and without regard to the individual’s age, type or nature of disability, severity of disability, or the form of home and community-based attendant services and supports that the individual requires in order to lead an independent life.

Other Unique Requirements: 

MOE requirement for 1st fiscal year for services provided under §1115, §1905(a), and §1915, of the Act.

Must establish & consult with a Development & Implementation Council with majority representation from consumers.

Cannot cover:

  • Certain assistive devices & assistive technology services; medical supplies & equipment, home modifications.
  • Room & board costs except for allowable transition services.
  • Special education and related services provided under IDEA that are education related only & vocational services provided under Rehab Act of 1973.

Increased FMAP

§1915(k)(2) of the Act provides that States offering this option to eligible individuals during a fiscal year quarter occurring on or after October 1, 2011 will be eligible for a 6 percentage point increase in the Federal medical assistance percentage (FMAP).

Case Management: 

Conflict of interest requirements apply under 42 CFR §441.555

Person-centered planning requirements apply under 42 CFR §441.540

Limits on Numbers Served: 

Not allowed.

Waiting Lists: 
Not allowed.
Combining Service Populations: 
States may combine service populations.
Caps on Individual Resource Allocations or Budgets: 
May determine process for setting individual budgets for participant-directed services.
Allowable Services: 


  • Assistance w/ ADLs, IADLs, & health related tasks.
  • Acquisition, maintenance & enhancement of skills necessary for individual to accomplish ADLs, IADLs, & health-related tasks.
  • Back-up systems or mechanisms to ensure continuity of services & supports.
  • Voluntary training on how to select, manage and dismiss staff.


  • Fiscal Management Services
  • Transition costs linked to an assessed need for an individual to transition from an institution for mental disease to the community.
  • Expenditures relating to an identified need that increases his/her independence or substitutes for human assistance.
Allowable Participant Settings: 

HCB settings rules apply

42 CFR §441.530

Regulations and CMS Guidance

Provider Qualifications: 

Determined by state, subject to CMS approval.

Participant-directed Services: 
Hiring of Legally Responsible Individuals: 
Allowed at the State’s discretion.
Cash Payments to Participants: 
Direct cash payments are permitted.
Financial Management Services: 

Required depending on model of participant direction. May be covered as a service, an administrative function, or performed directly by the SSMA.

Employer Status for Participant Direction: 

Agency Provider Model: Services & supports provided by entities under contract or provider agreement. Participant has a significant role in the selection and dismissal of providers. Entity may provide services directly through their employees or arrange for the provision of services under the direction of the individual receiving services.

Self-Directed Model with Service Budget: Service plan and budget directed by the individual and based on functional needs assessment. FMS must be available (SSMA may perform). Direct cash or vouchers may also be used.

Other Service Delivery Model: States may propose other models

Goods and Services: 
Permitted as a service.
Direct Payment of Providers: 

Required. State may use alternative voluntary option of an Organized Health Care delivery System to make payments.

Exception allowed under §447.10 Prohibition against reassignment of provider claims.

§447.10(g)(4): In the case of a class of practitioners for which the Medicaid program is the primary source of service revenue, payment may be made to a third party on behalf of the individual practitioner for benefits such as health insurance, skills training and other benefits customary for employees.

Provider Payments: 

Payment item must be listed in the service plan (plan of care), provided by an enrolled provider, and provided prior to reimbursement.

Cost Requirements: 

None. Benefit limits may apply.

For the first full fiscal year in which the State Plan amendment is implemented, a State must maintain, or exceed, the level of expenditures for services provided under §1115, §1905(a), and §1915, of the Act, or otherwise to individuals with disabilities or elderly individuals attributable to the preceding fiscal year.

Quality Management: 

Requires a quality assurance and improvement plan including how state conducts discovery, remediation, and quality improvement.

State must provide system of performance measures, outcome measures, and satisfaction measures that will be monitored and evaluated.

Interaction with State Plan Services, Waivers & Amendments: 

Individuals may be eligible for and receive State plan, §1915(c), §1915(i) and §1915(j)/§1915(k) services simultaneously.

May be combined with other waivers such as §1915(a) or (b).