The Community First Choice Option is among the lesser-known provisions of the Affordable Care Act. Formally known as Section 2401, this program offers states additional Medicaid funding to provide home- and community-based attendant services and other support to low-income disabled Americans, keeping them in the community and out of nursing homes.

Under the program, states can get a 6 percentage point increase in federal Medicaid matching payments to cover costs associated with providing community-based services such as assistance with activities of daily living and instrumental activities of daily living, as well as health-related tasks. States also would have the option of paying for transitions costs, such as the first month’s rent when a person moves from a nursing facility back to the community.

Eligibility and requirements associated with the program were outlined in a proposed rule in February; the program is scheduled to begin in October.

Kate Wilber, Ph.D., an expert on gerontology issues from the University of Southern California, explained how the program could help keep more disabled people in the community.

QUESTION: Who will be eligible for assistance under the Community First Choice Option?

DR. WILBER: Potential participants must live in a state that offers the program, qualify to receive medical assistance under their state’s Medicaid program, and have an income below 150% of the Federal Poverty Line. Individuals with higher incomes may participate if they are eligible for a nursing facility level of care that would be covered by the state Medicaid program. Right now, it is unclear how many states will choose to offer the program.

QUESTION: About 35 states already provide some type of personal care services through Medicaid. Is the increased federal payment likely to expand this much?

DR. WILBER: Close to half of the states have expressed interest in the program. The use of the increased federal match as an incentive is attractive. However, in contrast to waiver services with limited slots, this program is an entitlement, meaning it must be offered to everyone who is eligible. States that have concerns about offering a new entitlement in the current economic climate might take a "wait and see" attitude.

QUESTION: What impact will this have on nursing home care?

DR. WILBER: The resident mix in nursing homes has changed dramatically over the last decade or so, driven by several different factors that support expanded community options. In the 1999 Olmstead decision, the U.S. Supreme Court ruled that institutionalizing individuals who prefer to live in a community setting is discrimination, and that services should be provided in the most integrated and least restrictive setting. Over the last decade, the Centers for Medicare and Medicaid Services (CMS) have sought to reduce the Medicaid bias toward institutionalization by "rebalancing" funding toward more home and community-based service options. One initiative to promote rebalancing, known as "money follows the person," offers state incentives to transition long-stay residents out of facilities and into the community. States have also taken advantage of Medicaid waiver programs that permit individuals who are eligible for a nursing home level of care to use community-based services instead. The federal government has also funded demonstration programs to test the effectiveness of programs that offer consumer direction by providing cash benefits to purchase services. The Community First Option draws on and expands these options.

QUESTION: How can primary care physicians direct their disabled patients toward these programs?

DR. WILBER: Many primary care physicians are not familiar with long-term care services and supports, and the pathway from providing primary care to these services is not easy to find. Some physicians working in larger systems will have access to social workers who can assist with broader care planning for patients with complex conditions. Physicians are probably most familiar and most comfortable with skilled nursing facilities and home health care. Beyond that, there are a variety of programs with complex eligibility requirements, various levels of quality, and different funding sources. This is the system that the Institute of Medicine described as "a nightmare to navigate." Although the ACA attempts to address fragmentation, programs such as Community First will be shaped at the state level. Different states will have different approaches, with some choosing not to pursue the program at all. We will know more about what these programs will look like as states begin to develop their approaches.

QUESTION: The program requires a "person-centered planning process" and gives individuals the authority to hire, fire, and train their attendants. How does that improve the care provided?

DR. WILBER: Long-term care services and supports are "high touch," highly intrusive personal services that deal with many facets of a person’s life, often for many hours a day over a long period of time. For those receiving these services, it helps to have control over who provides them. Self-direction means care receivers have the authority to tailor their services according to their preferences, needs, cultural expectations, habits, and other lifestyle requirements. Evidence from self-directed care, such as the "Cash and Counseling" demonstrations have found that these services have good outcomes for the care recipient and caregivers, and are cost effective as well.

This column, "Implementing Health Reform," regularly appears in Internal Medicine News, an Elsevier publication. Kate Wilber, Ph.D., is the Mary Pickford Foundation Professor of Gerontology at the University of Southern California in Los Angeles.

Perspective: Community First Choice Option