Overview of the Apple Health Community First Choice Program
Washington State’s Community First Choice (CFC) Program provides a suite of long-term services and supports for state residents who require a nursing home level of care but chose to receive care outside of a nursing home. Also called the Community First Choice Option (CFCO), program benefits are intended to assist the elderly and disabled in independent living. Personal care, such as assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs), are provided. Examples include bathing, dressing, mobility, medication management, toiletry, meal preparation, and housekeeping. Other benefits include personal emergency response systems, assistive technology, and respite care.
Services are offered in one’s personal home, the home of a family member, an adult family home (similar to adult foster care), or an assisted living facility. Assisted living facilities include adult residential care facilities and enhanced adult residential care facilities.
Persons have the option of receiving in-home personal care assistance from a licensed care agency worker or an “individual provider”. The individual provider option allows program participants to self-direct their own care, which means they hire, supervise, and can even fire, the caregiver of their choosing. While friends and select relatives can be hired as the individual provider, they must be 18+ years old, qualified to provide such care, and have a contract with the Washington State Department of Social and Health Services (DSHS). Spouses, unfortunately, cannot be hired as the caregiver.
CFC services are an entitlement, which means meeting the state’s Medicaid eligibility requirements guarantees one will receive benefits. Put differently, there is never a wait 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. The Medicaid Program in Washington State is called Washington Apple Health or Apple Health.
Benefits of the Community First Choice Program
Follows is a list of home and community based services and supports available via WA’s Community First Choice Program. An individual care plan determines which benefits and the number of service hours a program participant receives.
– Assistive Technology – to increase independence (i.e., dressing aids, light sensors, alarm reminders, talking pill box)
– Community Transitional Services – to assist persons in transitioning from a nursing home back into the community (i.e., security deposit, utility set-up fees, essential household items)
– Nursing Tasks – specific nursing tasks assigned by a registered nurse to a home care aide / nursing assistant (i.e., medication administration, insulin injections, monitoring of blood glucose, ostomy care)
– Personal Care Assistance – assistance with bathing, toiletry, mobility, eating, light housecleaning, meal preparation, essential shopping, etc.
– Personal Emergency Response System (PERS)
– Respite Care – also called relief care and allows a primary caregiver a break from caregiving
– Training – skills acquisition to increase ability to live independently / caregiver management
While services are available in adult family homes and assisted living facilities, the cost of room and board is not covered by CFC.
The Community First Choice (CFC) Option 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.
Eligibility Requirements for Washington State’s Community First Choice Program
The CFC suite of services is for WA State residents who are eligible for the state’s Medicaid (Apple Health) plan. The information below is relevant for the elderly (65+ years of age) and disabled.
Financial Criteria: Income, Assets & Home Ownership
The applicant income limit is equivalent to 100% of the Federal Benefit Rate (FBR), which increases on an annual basis in January. In 2021, a single applicant can have a monthly income up to $794. Persons who have income greater than this amount can be considered under the income eligibility rules for a HCBS (home and community based services) Medicaid Waiver program (i.e., COPES). This allows for a higher monthly income limit of $2,382. To be clear, this means that an applicant is applying for the waiver program for long-term care, but will be able to access personal care assistance via CFC.
When both spouses are applicants, the couple is limited to $1,191 / month in income. If the couple’s monthly income is higher than $1,191, they can apply for a HCBS Medicaid Waiver to access CFC services. This allows each spouse up to $2,382 / month in income.
When only one spouse is an applicant, the applicant income limit is $794 / month. The income of the non-applicant spouse is not counted towards the income eligibility of his/her spouse. Applicants who have income in excess of this amount can apply via the HCBS Medicaid waiver income limit of $2,382 / month. 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. The maximum amount that can be transferred is $3,260 / month (effective January 2021 – December 2021) and is intended to ensure the non-applicant spouse has a minimum monthly income of this amount. Non-applicant spouses who have their own income equal to or greater than this amount are not entitled to a spousal income allowance.
In 2021, the asset limit is $2,000 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 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.
While there is a 60-month look back rule in which Medicaid checks past asset transfers of persons applying for nursing home Medicaid or home and community based services via a Medicaid waiver, this is not relevant for the Community First Choice Program. However, if one accesses CFC via a HCBS Medicaid Waiver, the look back rule applies, which means assets should not be given away or sold under fair market value prior to applying for long-term care Medicaid.
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, WA State 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.
– The applicant’s spouse lives in the home.
– The applicant’s disabled or blind child lives in the home.
– The applicant’s minor child (under 21 years old) lives in the home.
To learn more about the potential of Medicaid taking the home, click here.
Medical Criteria: Functional Need
An applicant must require a nursing facility level of care (NFLOC) to be eligible for CFC services. The Comprehensive Assessment Reporting Evaluation (CARE) tool is used to determine if this level of care need is met. To meet the care need, one must require daily nursing care OR require assistance with their activities of daily living / ADLs (i.e., transferring from the bed to a chair, repositioning oneself in bed, mobility / getting from one place to another, eating, toileting, bathing, and medication management). One must require substantial assistance with at least 2 ADLs or require some assistance with 3 or more ADLs. Relevant to some persons with Alzheimer’s disease or a related dementia, cognitive impairments, such as memory loss, lack of focus, and difficulty making plans, can result in the need for assistance with ADLs. In this case, the individual must require supervision as well as substantial assistance with one ADL. A diagnosis of dementia in and of itself does not mean one will meet a NFLOC.
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.
While Washington State has a Spenddown Program that permits Medicaid applicants to spend “excess” income on medical expenses in order to meet Medicaid’s income limit, the CFC Program prohibits persons from qualifying via this avenue.
When persons have assets over the limits, trusts are an option. Irrevocable Funeral Trusts are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Persons can also “spend down” assets over the limit on past due bills, household furnishings / appliances, and home modifications. 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 to meet Medicaid’s financial eligibility criteria without violating Medicaid’s 60-month look back period and jeopardizing Medicaid eligibility. Furthermore, there are additional planning strategies that not only help one meet Medicaid’s financial criteria, but also protects assets from Medicaid’s estate recovery program, preserving them instead for family as inheritance. While some of these strategies violate the look back rule and should be implemented well in advance of the need for long-term care, there are some workarounds. WA State Medicaid planners are well aware of them, and therefore, it is highly suggested persons consult one for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid planner.
How to Apply for the Community First Choice Program
Before You Apply
Prior to submitting an application for CFC services, applicants need to ensure they meet the Washington State 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, previous bank statements, 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.
To apply for CFC services, persons must be eligible for Washington State Medicaid / Apple Health. Seniors who are not already enrolled in WA Medicaid can apply online or via their local Home and Community Services (HHS) office. Contact information for local offices can be found here, and a Washington Apple Health Application for Aged, Blind, Disabled / Long-Term Care Coverage can be downloaded here. Seniors who are already enrolled in Medicaid, should contact their local HHS office to initiate the process for CFC services.
Applicants will undergo an in-person functional needs assessment as part of the application process for CFC benefits.
The Washington State Department of Social and Health Services (DSHS) administers the CFC Program. The Division of Home and Community Services (HCS) determines financial eligibility. The Aging and Long-Term Support Administration (ALTSA) and the Developmental Disabilities Administration (DDA) determine functional eligibility.
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 even further. 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.