Community First Choice (CFC) Program from Maryland Medicaid / Medical Assistance

Last updated: May 30, 2024


Overview of the Community First Choice Program

Maryland’s Community First Choice (CFC) Program is a suite of long-term services and supports for persons who are elderly or disabled and require care equivalent to that which is provided in a nursing home. Intended to prevent and delay unnecessary nursing facility admissions, assistance with Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) is provided. This includes personal care assistance (i.e., bathing, dressing, toileting, and eating) and homemaker services (i.e., preparing meals, light housecleaning, and laundry). Other benefits might include personal emergency response systems, home modifications for safety and accessibility, and delivery of prepared meals.

The services offered under this program may be provided by licensed agency workers or program participants have the option to self-direct their personal care services. The self-directed option allows for the hiring of a relative or friend to provide care. This includes an adult child or spouse, given that person is not the program participant’s guardian or acting as the program representative (making program decisions on the program participant’s behalf). Furthermore, the “caregiver” must become employed by a Medicaid Personal Assistance Agency. A fiscal intermediary handles the financial aspects of employment responsibilities, such as tax withholding and caregiver payments.

Program participants must reside in their own home or the home of a friend or relative. Services cannot be provided to persons living in assisted living residences.

CFC services are an entitlement. This means meeting the state’s Medicaid eligibility requirements guarantees one will receive benefits. Put differently, there is never a waiting list to receive Community First Choice benefits.

The Community First Choice Program is a Medicaid State Plan Option that was created by the Affordable Care Act (ACA). It is a 1915(k) State Plan Amendment. Medicaid in Maryland is called Medical Assistance. For the elderly, it is called Medical Assistance for the Aged, Blind, and Disabled.

 What is the Community First Choice Option?
The Community First Choice (CFC) Option, established by the Affordable Care Act, allows states to provide limited home and community based services (HCBS), such as personal care assistance, via their state’s Regular Medicaid program. Previously, states mainly provided HCBS via 1915(c) Medicaid Waivers, which limit the number of participant enrollment slots. Therefore, waiting lists commonly exist. In contrast, CFC benefits are available via a state’s Regular Medicaid program, which does not limit the number of program beneficiaries. This means the availability of home and community based services via the CFC Option is open to anyone who meets the eligibility criteria.


Benefits of Community First Choice

Follows is a list of potential home and community based services and supports available via Community First Choice. An individual care plan will determine which services and supports a program participant will receive.

– Accessibility Adaptations – i.e., wheelchair ramps, widening of doorways, roll-in showers
– Assistive Technology – i.e., aids that help a person do day-to-day activities
– Consumer Training – i.e., money management / budgeting, planning meals, independent living
– Home Delivered Meals
– Environmental Assessments
– Nurse Monitoring
– Personal Assistance Services – assistance with bathing, grooming, personal hygiene, transferring, meal preparation, shopping for essential items, basic housecleaning, etc.
– Personal Emergency Response System (PERS) – includes device and monthly fees
– Supports Planning – assistance with developing a care plan
– Transition Services – provides security deposit and utility set-up fees for persons transitioning from a nursing home into a personal home

Persons eligible for Community First Choice may also be able to receive other Medicaid services, such as physician visits, hospitalization, home health care, laboratory services, durable medical equipment, and disposable medical supplies.


Eligibility Requirements for MD’s Community First Choice

The CFC suite of long-term care services is for Maryland residents of all ages who are eligible for the Medicaid State Plan / Medical Assistance, or specific to seniors, the Medical Assistance for the Aged, Blind, and Disabled program. The criteria below is relevant for the elderly (65+ years of age) and persons who are disabled.

 The American Council on Aging provides a quick and easy Maryland Medicaid Eligibility Test for seniors
Financial Criteria: Income, Assets & Home Ownership

In 2024, the individual applicant income limit is $350 / month, and the couple income limit with both spouses as applicants is $392 / month. When only one spouse is an applicant, the individual income limit of $350 / month is used. Stated differently, the income of the non-applicant spouse is not counted towards the income eligibility of their spouse. Furthermore, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a Spousal Income Allowance, also called a Monthly Maintenance Needs Allowance.

In Maryland, there is a minimum income allowance, set at $2,555 / month (eff. July 2024 – June 2025). This allows an applicant spouse to supplement their non-applicant spouse’s monthly income, bringing their income up to this amount. There is also a maximum income allowance, which in 2024, is $3,853.50 / month. While this potentially allows a non-applicant spouse a higher income allowance, any additional amount above the minimum income allowance is dependent on one’s shelter and utility costs. A Spousal Income Allowance, however, can never push a non-applicant’s total monthly income over $3,853.50. This Monthly Maintenance Needs Allowance is intended to ensure the non-applicant spouse does not become impoverished.

 There are other avenues through which Maryland seniors might be financially eligible for Community First Choice. For instance, persons who receive Supplemental Security Income (SSI) automatically qualify for MD Medicaid. Furthermore, persons enrolled in the Community Options Medicaid Waiver may receive services and supports via Community First Choice. Persons who qualify for CFC via the Waiver program are allowed a higher monthly income than those who qualify via the Regular State Medicaid Plan or SSI.

In 2024, the asset limit is $2,500 for a single applicant. For married couples, with both spouses as applicants, the asset limit is $3,000. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are still limited. This is because Medicaid considers the assets of a married couple to be jointly owned. In this case, the applicant spouse can retain up to $2,500 in assets and the non-applicant spouse is allocated a larger portion of the couple’s assets as a Community Spouse Resource Allowance (CSRA) to prevent spousal impoverishment. The CSRA allows the non-applicant spouse to keep 50% of the couple’s assets, up to $154,140. If the non-applicant’s share of assets falls under $30,828, they can keep 100% of the assets, up to $30,828.

Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.

Assets should not be given away or sold under fair market value prior to applying for long-term care Medicaid. This is because MD Medicaid has a 60-month Look-Back Rule for applicants of long-term home and community based services. Violating this rule results in a Penalty Period of Medicaid ineligibility.

 To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our Spend Down Calculator.  

Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take it. Fortunately, for eligibility purposes, Maryland Medicaid considers the home exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has “Intent” to Return, and in 2024, their home equity interest is no greater than $713,000. Home equity is the current value of the home minus any outstanding mortgage. Equity interest is the portion of the home’s equity value that is owned by the applicant.
– A spouse lives in the home.
– The applicant has a minor child living in the home.
– The applicant has a disabled relative living in the home.

Learn more about the potential of Medicaid taking the home here.

 Maryland residents who require personal care assistance, but do not require the level of care provided in a nursing home, should consider the Community Personal Assistance Services Program.


Medical Criteria: Functional Need

An applicant must require a Nursing Facility Level of Care (NFLOC) to be eligible for CFC services. The assessment tool used to make this level of care determination is the interRAI Home Care (HC). This assessment contains twelve categories relative to daily living. Points are assigned based on the amount and level of assistance required. The higher the score, the greater the level of care need. Several categories are Activities of Daily Living (ADLs), which are essential for day-to-day functioning, and include mobility, eating, toileting, bathing, and dressing / grooming. Relevant to many persons with Alzheimer’s disease or a related dementia, cognition, such as decision making ability, memory, and comprehension, are also considered. A diagnosis of dementia in and of itself does not mean one will meet a NFLOC.

 Learn about long-term care Medicaid in Maryland.


Qualifying When Over the Limits

Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.

Maryland has a Medically Needy Spend-Down Program for applicants who have high medical expenses relative to their income. Via this program, applicants are permitted to spend “excess” income on medical expenses and health care premiums, such as Medicare Part B, in order to meet Medicaid’s income limit.

When persons have assets over the limits, one option is to “spend down” assets. Examples include paying off debt, making home improvements, such as updating heating and plumbing, and purchasing pre-paid funeral and burial expense trusts called Irrevocable Funeral Trusts. Though no longer a strategy frequently used, married couples with a significant amount of assets sometimes get a Medicaid Divorce to preserve assets for the non-applicant spouse. There are many other options when the applicant has assets exceeding the limit.

Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid Planners are educated in the planning strategies available in Maryland to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid / Medical Assistance eligibility. There are also planning strategies that not only help one meet Medicaid’s financial criteria, but also protects assets from Medicaid’s Estate Recovery Program, preserving them for family as inheritance. These strategies often violate Medicaid’s 60-month Look-Back Period, and therefore, should be implemented well in advance of the need for long-term care. However, there are some workarounds, and Medicaid Planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid Planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid Planner.


How to Apply for MD Medicaid Community First Choice

Before You Apply

Prior to submitting an application for CFC services, applicants need to ensure they meet the Maryland Medicaid eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid Eligibility Test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid Eligibility Test.

As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements up to 60-months prior to application, proof of income, copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.


Application Process

To apply for CFC, persons should contact the Office of Long Term Services and Supports at 410-767-1739 or Maryland Access Point (MAP) at 844-627-5465. Persons can also contact their local MAP office. A functional needs assessment will be completed by the local health department as part of the application process.

Persons can learn more about the Community First Choice Program here. The Maryland Department of Health’s (MDH) Office of Long Term Services and Supports administers the CFC Program.


Approval Process & Timing

The Medical Assistance (Maryland Medicaid) application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed. Based on federal law, Medicaid offices have up to 45 days to review and approve or deny one’s application (up to 90 days for disability applications). Despite the law, applications are sometimes delayed even further.

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