K Plan / Community First Choice Option from Oregon Health Plan (Medicaid)

Last updated: October 20, 2021

 

Overview of Oregon K Plan / Community First Choice Option

Oregon’s K Plan, formally called the Community First Choice State Plan Option, provides home and community based services (HCBS) for elderly and disabled persons who require a level of care equivalent to that which is provided in a nursing home. Intended to prevent and delay unnecessary nursing facility admissions, attendant services are provided. This includes activities of daily living (ADLs) and instrumental activities of daily living (IADLs), such as bathing, dressing, toileting, eating, preparing meals, light housecleaning, and laundry. Other benefits might include personal emergency response systems, safety and accessibility home modifications, adult day care, and home delivered meals.

The services offered under this program may be provided by licensed agency workers or program participants have the option to self-direct their attendant care. The self-directed option allows for the hiring of a friend or relative to provide care. Family members who are qualified to be hired as caregivers include sons, daughters, adult grandchildren, nieces, and nephews, but not spouses or legal guardians. Program participants who cannot self-direct their own care, may choose a representative to do so on their behalf. However, the representative cannot also be the paid caregiver. The financial aspects of being an employer, such as tax withholding and issuing caregiver payments, are handled by the state.

 While spouses cannot be paid to provide care via the Oregon K Plan, they can be paid to provide care via the Spousal Pay Program, which is part of the Consumer-Employed Provider (CEP) Program. Furthermore, there is an additional consumer-directed program that allows friends and family, including spouses, to be the paid caregiver. This is the Independent Choices Program (ICP).

Program participants can reside in their own home, the home of a friend or relative, an adult foster care home, an assisted living residence, or a memory care facility, which provides specialized care for persons with Alzheimer’s disease and related dementias.

K Plan / 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 wait list to receive K Plan benefits.

The K Plan, also known as the Community First Choice (CFC) Program, is a Medicaid state plan option that was created by the Affordable Care Act (ACA). It is a 1915(k) State Plan Amendment. In OR, the Medicaid program is called the Oregon Health Plan (OHP). The Medicaid program specific to the aged, blind or disabled through which medical and long term care services are available is the Oregon Supplemental Income Program-Medical (OSIPM).

 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, wait 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 the K Plan / Community First Choice Option

Follows is a list of potential home and community based services and supports available via the K Plan. An individual service plan will determine which benefits a program participant will receive. All program participants receive case management.

– Adult Day Care
– Attendant Care – includes personal care assistance and homemaker services (i.e., bathing, dressing, grooming, toileting, mobility, basic housecleaning, laundry, shopping for essentials)
– Backup Systems / Assistive Technology – i.e., personal emergency response systems, medication reminder devices, automatic faucets, fall sensors, lift chairs, wandering alerts
– Chore Services – i.e., heavy cleaning for safety purposes, removal of hazardous debris outdoors
– Community Transportation
– Consumer Training – voluntary training for persons self-directing their care – i.e., how to select, manage, and fire caregivers
– Durable Medical Equipment – i.e., walkers, wheelchairs
– Home Delivered Meals
– Home Modifications – home access ramps, hand rails, grab bars, electronic door openers, raised toilets, non-skid surfaces, lowering counters / sinks for wheelchair access
– Medication Management
– Memory Care Support – observation, supervision, and intervention for cognitively impaired persons for safety purposes
– Nursing Services
– Relief Care – alternative care if primary caregiver is unable to provide care
– Positive Behavioral Support Services
– Transition Services – provides basic household items / furnishings, housing application fees, background / credit check fees, cleaning deposits, security deposits, utility deposits for persons transitioning from a nursing home back home or into the community

While CFC / K Plan services and supports can be provided in adult foster care homes, assisted living residences, and memory care facilities, the cost of room and board is not covered.

 

Eligibility Requirements for K Plan / Community First Choice Option

The K Plan’s long-term care services and supports are for Oregon residents of all ages who are eligible for OR’s state Medicaid plan, or specific to seniors, the Oregon Supplemental Income Program-Medicaid (OSIPM). Additional criteria is below and is relevant for the elderly (65+ years of age).

 The American Council on Aging provides a quick and easy Medicaid eligibility test for Oregon seniors requiring ongoing assistance. Start here

 

Financial Criteria: Income, Assets & Home Ownership

Income
The applicant income limit is equivalent to 300% of the Federal Benefit Rate (FBR), which increases on an annual basis in January. In 2021, an applicant, regardless of marital status, can have a monthly income up to $2,382. When both spouses are applicants, each spouse is considered individually, with each spouse allowed income up to $2,382 / month. When only one spouse is an applicant, the income of the non-applicant spouse is not counted towards the income eligibility of his/her 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 OR, there is a minimum income allowance, set at $2,177.50 / month (effective July 2021 – June 2022). This is intended to bring a non-applicant spouse’s monthly income up to this amount. There is also a maximum income allowance, which is $3,259.50 / month (effective January 2021 – December 2021), and is dependent on the non-applicant spouse’s shelter and utility costs. This monthly maintenance needs allowance is intended to ensure the non-applicant spouse does not become impoverished. To be clear, a non-applicant spouse’s own monthly income combined with the income allowance from the non-applicant spouse cannot exceed $3,259.50.

Assets
In 2021, the asset limit is $2,000 for a single applicant. For married couples, with both spouses as applicants, each spouse can have up to $2,000 in assets. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are limited, though the non-applicant spouse is allocated a larger portion of the assets to prevent spousal impoverishment. (Unlike with income, Medicaid considers the assets of a married couple to be jointly owned). In this case, the applicant spouse can retain up to $2,000 in assets and the non-applicant spouse can keep up to $130,380. This larger allocation of assets to the non-applicant spouse is called a community spouse resource allowance.

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 OR 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 their home. Fortunately, for eligibility purposes, Oregon Medicaid considers the home exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has “intent” to return to the home and his / her home equity interest is no greater than $603,000. Home equity interest is the current value of the home minus any outstanding mortgage.
– A spouse lives in the home.
– The applicant has a disabled or blind child (any age) living in the home.
– The applicant has a minor child (under 21) living in the home.

To learn more about the potential of Medicaid taking the home, click here.

 Oregon residents who require personal care assistance, but do not require the level of care provided in a nursing home, should consider OR’s State Plan Personal Care Program (SPPC)./

 

Medical Criteria: Functional Need

An applicant must require a nursing facility level of care (NFLOC). For the K Plan / CFC, the tool used to determine if this level of care need is met is the Client Assessment and Planning System (CAPS). An applicant’s ability to complete activities of daily living (i.e., transferring from the bed to a chair, mobility, eating, toileting, bathing) and instrumental activities of daily living (i.e., housekeeping, medication management, shopping, laundry) are assessed. Relevant to some persons with Alzheimer’s disease or a related dementia, behavioral problems, such as regular attempts to leave the facility or removal of one’s clothes, are also considered. A diagnosis of dementia in and of itself does not mean one will meet a NFLOC. A service priority level is generated during the assessment process. There are 18 levels, with 1 being the highest level of assistance required and 18 the least. For the K Plan, an applicant must receive a service priority level between 1 and 13.

 For more information about long-term care Medicaid in Oregon, click here.

 

Qualifying When Over the Limits

Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for OR 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.

When persons have income over the limits, Miller Trusts, also called a qualified income trust can help. “Excess” income is deposited into the trust, no longer counting as income.

When persons have assets over the limits, trusts are an option. Irrevocable Funeral Trusts (IFTs) are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. IFTs are just one way in which applicants can “spend down” excess assets on exempt assets. Persons can also buy household items and furnishings, trade in their vehicle, or take a vacation. Annuities provide another way for persons to lower their countable assets. This technique turns a lump sum of cash into a monthly stream of income. There are many alternative solutions 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 OR to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. There are also planning strategies that not only help one meet Medicaid’s financial criteria, but also protect assets from Medicaid’s estate recovery program and instead preserves assets for family as inheritance. These strategies often violate Medicaid’s 60-month look back rule, 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 Oregon K Plan / Community First Choice Option

Before You Apply

Prior to submitting an application for K Plan / CFC services, applicants need to ensure they meet the Oregon 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 the K Plan / Community First Choice Option, applicants should contact their local Area Agency on Aging (AAA) office or Aging and People with Disabilities (APD) office. Contact information by county can be found here.

For additional information about the K Plan, click here. Persons can also contact the Aging and Disability Resource Connection (ADRC) at 1-855-673-2372. The Oregon Department of Human Services (ODHS) Office of Aging and People with Disabilities administers the K Plan.

 

Approval Process & Timing

The 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. In most cases, it takes between 45 and 90 days for the Medicaid agency to review and approve or deny one’s application. Based on law, Medicaid offices have up to 45 days to complete this process (up to 90 days for disability applications). However, despite the law, applications are sometimes delayed even further.

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