Section 17000, Non-Waiver Community First Choice (CFC)

Revision 19-4; Effective September 9, 2019

 

Non-waiver CFC provides certain services and supports through managed care organizations (MCOs) to persons living in the community who are enrolled in the Medicaid program and meet CFC eligibility requirements.

 

17100 Initial Eligibility Determination Activities

Revision 19-4; Effective September 9, 2019

 

For persons referred to the local intellectual and developmental disability authority (LIDDA) for assessments of eligibility for Community First Choice (CFC) services based on an intellectual disability (ID), the LIDDA must complete all assessment activities required by Texas Health and Human Services Commission (HHSC) to determine whether the persons meet an intermediate care facility for individuals with intellectual disabilities or related conditions (ICF/IID) level-of-care (LOC) including:

The LIDDA must submit the assessment information to HHSC using the Client Assignment and Registration (CARE) System for an LOC determination.

If the person’s primary diagnosis is a related condition, the LIDDA must:

 

17110 Person Does Not Meet ICF/IID LOC Criteria

Revision 19-4; Effective September 9, 2019

 

For all persons for whom Texas Health and Human Services Commission (HHSC) has determined does not meet the criteria for an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) level-of-care (LOC), the local intellectual and developmental disability authority (LIDDA) must compile a packet with the following documentation and submit it to the Medicaid managed care organization (MCO) via the secure file transfer protocol (SFTP) site:

 

17120 Person Meets ICF/IID Criteria Under Age 21

Revision 19-4; Effective September 9, 2019

 

For persons under the age of 21 years for whom Texas Health and Human Services Commission (HHSC) has determined does meet the criteria for an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) level-of-care (LOC), the local intellectual and developmental disability authority (LIDDA) must compile a packet with the following documentation and submit it to the Medicaid managed care organization (MCO) via the secure file transfer protocol (SFTP) site:

The LIDDA does not provide service coordination for persons under 21 years of age and receiving Community First Choice (CFC) through the MCO.

 

17130 Person Meets ICF/IID Criteria Age 21 and Older

Revision 19-4; Effective September 9, 2019

 

For persons with an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) level-of-care (LOC), the local intellectual and developmental disability authority (LIDDA) must conduct the initial service planning activities and assign a service coordinator no later than 30 days after Texas Health and Human Services Commission (HHSC) authorizes the person’s ICF/IID LOC.

The LIDDA must conduct person-centered service planning with the person and the legally authorized representative (LAR). The LIDDA will contact the person or LAR to schedule a time to meet and complete the Community First Choice (CFC) assessment. The meeting is conducted face-to-face with the person and LAR. The LAR may attend by telephone if the LAR is unable to attend in person. The time and location of the meeting must be convenient to the person and LAR.

At the scheduled meeting, the LIDDA must:

The LIDDA must compile a packet with the following documentation and submit it to the MCO via the secure file transfer protocol (SFTP) site:

When the MCO receives the packet from the LIDDA, the MCO determines if the person has a need for CFC services.

If no services are on the recommended service plan (i.e., Form H6516 completed by the LIDDA, the MCO denies the request for services and sends the person an adverse determination letter, which includes an offer for a fair hearing. The LIDDA must participate in a fair hearing, if requested by the person or LAR, to explain why no services were recommended.

If there are services on the recommended service plan, but the MCO does not agree with the services recommended, the MCO service coordinator contacts the LIDDA to discuss the service plan and to reach an agreement about changes to the service plan that will be presented to the person. Following an agreement, the MCO service coordinator, person, LAR and LIDDA meet to jointly review the services for which the person will be authorized. The MCO then authorizes services and notifies the person. The MCO also notifies the LIDDA of the selected provider.

If there are services on the recommended service plan and the MCO service coordinator agrees with the services being recommended:

The LIDDA must ensure an assigned service coordinator provides service coordination to a person age 21 or older while the person is receiving CFC services through an MCO in the LIDDA’s local service area (LSA).

 

17200 Annual Reassessment

Revision 19-4; Effective September 9, 2019

 

No later than 60 calendar days prior to the expiration of the intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) level-of-care (LOC) for a person, the local intellectual and developmental disability authority (LIDDA) must communicate with the appropriate managed care organization (MCO) to determine whether the person is or is not receiving Community First Choice (CFC) services.
For persons who are not receiving CFC services, the LIDDA has no reassessment responsibilities.

For persons who are receiving CFC services, the LIDDA must:

The LIDDA should consider this if the person’s current determination of intellectual disability (DID) was completed when the person was under the age of 22 years and the testing was done more than five years ago. Information about conducting DIDs is found in the DID Best Practice Guidelines.

The LIDDA must submit the assessment information to HHSC using the Client Assignment and Registration (CARE) System for a LOC determination.

 

17210 Person No Longer Meets ICF/IID LOC Criteria

Revision 19-4; Effective September 9, 2019

 

For all persons for whom Texas Health and Human Services Commission (HHSC) has determined does not continue meet the criteria for an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) level-of-care (LOC), the local intellectual and developmental disability authority (LIDDA) must compile a packet with the following documentation and submit it to the managed care organization (MCO) via the secure file transfer protocol (SFTP) site:

 

17220 Person Continues to Meet ICF/IID Criteria Under Age 21

Revision 19-4; Effective September 9, 2019

 

For persons under the age of 21 years for whom Texas Health and Human Services Commission (HHSC) has determined does meet the criteria for an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) level-of-care (LOC), the local intellectual and developmental disability authority (LIDDA) must compile a packet with the following documentation and submit it to the managed care organization (MCO) via the secure file transfer protocol (SFTP) site:

The LIDDA does not provide service coordination for persons under 21 years of age and receiving Community First Choice (CFC) through the MCO.

 

17230 Person Continues to Meet ICF/IID Criteria Age 21 and Older

Revision 19-4; Effective September 9, 2019

 

The local intellectual and developmental disability authority (LIDDA) service coordinator is responsible for completing the annual service planning and continuation of LIDDA services for persons 21 years of age or older who continue to have an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) level-of-care (LOC).
The LIDDA must:

The meeting is conducted face-to-face with the person and LAR. The LAR may attend by telephone if the LAR is unable to attend in person. The time and location of the meeting must be convenient to the person and LAR.

At the scheduled meeting, the LIDDA must:

No later than 45 calendar days prior to the expiration of a person’s ICF/IID LOC, the LIDDA must compile a packet with the following documentation and submit it to the MCO via the secure file transfer protocol(SFTP) site:

When the MCO receives the packet from the LIDDA, the MCO determines if the person continues to have a need for Community First Choice (CFC) services.

If no services are on the recommended service plan (i.e., completed Form H6516), the MCO denies the request for services and sends the person an adverse determination letter, which includes an offer for a fair hearing. The LIDDA must participate in a fair hearing, if requested by the person or LAR, to explain why no services were recommended.

If there are services on the recommended service plan, but the MCO does not agree with the services recommended, the MCO service coordinator contacts the LIDDA to discuss the service plan and to reach an agreement about changes to the service plan that will be presented to the person. Following the agreement, the MCO service coordinator, person, LAR and LIDDA meet to jointly review the services for which the person will be authorized. The MCO then authorizes services and notifies the person.  

If there are services on the recommended service plan and the MCO service coordinator agrees with the services being recommended:

 
If the person selected a different provider, the MCO notifies the LIDDA of the name of the selected provider.

The LIDDA continues to provide service coordination to the person while they are receiving CFC services through an MCO in the LIDDA’s local service area.

 

17300 LIDDA Responsibilities When a Person Appeals an MCO’s Denial of Services

Revision 19-4; Effective September 9, 2019

 

If a managed care organization (MCO) denies a person’s request for service because there were no services on the person’s recommended service plan [i.e., Form H6516 completed by the local intellectual and developmental disability authority (LIDDA)] and the person requests a fair hearing to appeal the denial, the LIDDA must participate in the fair hearing to explain why no services were recommended.