Janice K. Brewer, Governor
Thomas J. Betlach, Director

801 East Jefferson, Phoenix, AZ 85034
PO Box 25520, Phoenix, AZ 85002
Phone: 602-417-4000
www.azahcccs.gov

Our first care is your health care
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

October 5, 2012

Cheryl Young
Centers for Medicare and Medicaid Services
75 Hawthorne St., 5th Floor
San Francisco, California  94105

Dear Ms. Young:

Enclosed is Arizona State Plan Amendment (SPA) 12-011, effective January 1, 2013, which describes the Community First Choice Option as described in Section 1915(k) of the Social Security Act in the State Plan.

If you have any questions about the enclosed SPA, please contact Theresa Gonzales at (602)

417-4732. Sincerely,

Monica Coury
Assistant Director
Office of Intergovernmental Relations

Cc: Jessica Schubel Mark Wong Cindy Lemesh

DEPARTMENT OF HEALTH AND HUMAN SERVICES	 FORM APPROVED CENTERS FOR MEDICARE AND MEDICAID SERVICES	OMB NO. 0938-0193
TRANSMITTAL AND NOTICE OF APPROVAL OF
STATE PLAN MATERIAL

FOR: Centers for Medicare and Medicaid Services	1. TRANSMITTAL NUMBER:
12-011	2. STATE
Arizona	
	3. PROGRAM IDENTIFICATION: TITLE XIX OF THE
SOCIAL SECURITY ACT (MEDICAID)	
TO: REGIONAL ADMINISTRATOR
CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES	4. PROPOSED EFFECTIVE DATE
January 1, 2013	
5. TYPE OF PLAN MATERIAL (Check One):

NEW STATE PLAN	AMENDMENT TO BE CONSIDERED AS NEW PLAN	AMENDMENT	
COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)	
6. FEDERAL STATUTE/REGULATION CITATION:
Section 1915(k) of the Social Security Act	7. FEDERAL BUDGET IMPACT:
$ Forthcoming based on pending waiver	
8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Page 19(c)
Attachment 3.1-A, Page 12
Supplement 3 to Attachment 3.1-A, Pages 1-5	9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION
OR ATTACHMENT (If Applicable):

Page 9 of Attachment 4.19-D	
10. SUBJECT OF AMENDMENT:

Updates the State Plan to describe the Community First Choice Option effective January 1, 2013.	
11. GOVERNOR’S REVIEW (Check One):
GOVERNOR’S OFFICE REPORTED NO COMMENT	OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR’S OFFICE ENCLOSED
NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL	
12. SIGNATURE OF STATE AGENCY OFFICIAL:	16. RETURN TO:

Monica Coury
801 E. Jefferson, MD#4200
Phoenix, Arizona 85034	
13. TYPED NAME:
Monica Coury		
14. TITLE:
Assistant Director		
15. DATE SUBMITTED:
October 5, 2012		
FOR REGIONAL OFFICE USE ONLY	
17. DATE RECEIVED:	18. DATE APPROVED:	
PLAN APPROVED – ONE COPY ATTACHED	
19. EFFECTIVE DATE OF APPROVED MATERIAL:	20. SIGNATURE OF REGIONAL OFFICIAL:	
21. TYPED NAME:	22. TITLE:	
23. REMARKS:	

FORM HCFA-179 (07-92)

19c

State of

Arizona

Citation	3.1(a)(1) Amount, Duration, and Scope of Services: Categorically Needy
(Continued)

 X_	Community First Choice Option (CFCO) services, as described and limited in
Supplement     3_ to Attachment 3.1-A.

Supplement 3 to Attachment 3.1-A identifies the CFCO services and supports provided to the categorically needy

TN No.:  12-011
Supersedes	Approval Date
TN No.:  N/A

Effective Date: January 1, 2013

State of

Arizona  	

Attachment 3.1-A Page 12

Amount, Duration, and Scope of Medical and Remedial Care Services Provided To the
Categorically Needy

28.   X      Community First Choice Option (CFCO) services, as described in Supplement 3 to
Attachment 3.1-A.

   X	Election of CFCO services:  By virtue of this submittal, the State elects CFCO
services as a State Plan service delivery option.

No election of CFCO Services: By virtue of this submittal, the State elects not to add CFCO Services as a State Plan service delivery option.

TN No.:  12-011
Supersedes	Approval Date
TN No.:  N/A

Effective Date: January 1, 2013

I.	Eligibility

State of Arizona

The State determines eligibility for Community First Choice Option (CFCO) in the manner as prescribed in the Social Security Act § 1915(k)(1) for individuals who have been determined eligible for the Arizona Long Term Care System.

II.	Delivery Model
The State elects to choose the following service delivery model and corresponding options to disperse funds to provide self-directed home and community-based attendant services and supports under the CFCO.:

_X_     Agency-provider model.
The State elects to choose the agency-with-choice model whereby the individual and the agency enter into a co-employment relationship and assume employer responsibilities. The agency assumes the responsibility to hire, fire and provide minimum standardized training required by the State.  The individual has the option to assume one or more of the following employer responsibilities to self-direct their care:
1)        Recruit and select providers including specifying provider qualifications
2)        Dismiss providers
3)	Supervise providers in the provision of services and supports that are within the scope of the approved person-centered service plan
4)	Manage providers in the provision of services and supports that are within the scope of the approved person-centered service plan
a.   Determine provider duties b.   Schedule providers
c.   Train providers in assigned tasks
5)        Require other training as needed, in order to meet the unique needs of the member

Self-directed model with service budget.
Financial management entity
Direct cash
Vouchers

TN No.:  12-011
Supersedes	Approval Date
TN No.:  N/A

Effective Date: January 1, 2013

State of

Arizona

IV.	Use of an Individual Representative
A.  _X_ The State elects to permit participants to appoint an individual representative, who is not a paid caregiver consistent with 42 C.F.R. 441.505, to serve as a representative for the purpose of approving services and/or service hours during the service planning process.
The State elects not to permit participants to appoint a representative to direct the provision of CFCO services on their behalf.

V.	CFCO Service Package
A.  Required Services- The State provides the following services that are within the scope of the approved person-centered service plan:
X_  Assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and health-related tasks through hands-on assistance, supervision, or cueing.
X_ Acquisition, maintenance, and enhancement of skills necessary for the individual to accomplish ADLs and IADLs.
X_   Backup systems or mechanisms to ensure continuity of services and supports. X_ Voluntary training for members on how to select, manage and dismiss attendants.
B.  Permissible Services. The State elects to provide the following services that are within the scope of the approved person-centered plan:
X_  Expenditures for transition costs such as rent and utility deposits, first month’s rent and utilities, bedding, basic kitchen supplies, and other necessities linked to an assessed need for an individual to transition from a nursing facility, institution for mental diseases, or intermediate care facility for the mentally retarded to a home and community-based setting where the individual resides;
X_  Expenditures relating to a need identified in an individual’s person-centered service plan that increases an individual’s independence or substitutes for human assistance, to the extent that expenditures would otherwise be made for the human assistance.

VI.	Service Plan
The State shall make available CFCO services and supports to eligible individuals:
A.  Under a person-centered plan of services and supports that is based on a face-to-face assessment of the individual’s functional need and that is fully disclosed in writing and agreed to by the participant, or as appropriate, their representative, and as outlined in 42 CFR 441.535 and .540; and
B.  In a home or community setting, which does not include a nursing facility,
institution for mental diseases, an intermediate care facility, or alternative residential setting.

TN No.:  12-011
Supersedes	Approval Date
TN No.:  N/A

Effective Date: January 1, 2013

VII.	Providers Qualifications
The State assures an individual who elects CFCO retains all rights related to training and qualification requirements established for providers as identified in 42 CFR 441.565.

VIII.	Quality Assurance and Improvement Plan
The State will ensure adherence to 42 CFR 441.585 through the following methods:
A. The AHCCCS Quality Assessment and Performance Improvement Strategy – The AHCCCS  Quality  Strategy  is  a  coordinated,   comprehensive,   and  pro-active approach to drive quality throughout the AHCCCS system by utilizing creative initiatives, monitoring, assessment, and outcome-based performance improvement. It  is  designed  to  ensure  that  services  provided  to  members  meet  or  exceed established  standards  for access  to  care,  clinical  quality of care,  and  quality of service. The Quality Strategy is based on the AHCCCS Mission and Vision, which includes specific emphasis on advocating for and delivering customer-focused care. Through that vision, AHCCCS will ensure that all members (including individuals electing the CFCO) maximize the independence and control and will infuse that concept into every relevant aspect of the Quality Strategy and related processes.
B.  Health Plan Monitoring and Oversight – Monitoring and oversight takes place at both the Contractor and State levels on an ongoing basis. Both Contractors and AHCCCS will ensure that training of members and their care providers meet state standards. Members will also be informed of the appeal process in case they do not agree with decisions in their person-centered service plan. In addition, ongoing education and outreach is provided to case managers and members/their individual representatives, regarding the mandatory reporting, investigation, and resolution of allegations of neglect, abuse, or exploitation.  Adequate staff is ensured at both the Contractor and State levels to address potential quality of care concerns in an appropriate and timely manner.
C. Performance Measures and other Quality Indicators – AHCCCS has developed a comprehensive process for monitoring health outcomes, including Contract- mandated performance measures that include minimum performance standards as well as Performance Improvement Projects when it is determined that a specialized focus would drive improvement.  AHCCCS will have specific, individual outcome- based measures in place to ensure that CFCO participants maintain optimal physical and emotional health and welfare.

TN No.:  12-011
Supersedes	Approval Date
TN No.:  N/A

Effective Date: January 1, 2013

IX.	Risk Management
The risk assessment methods and tools or instruments used to identify and mitigate potential risks to participants are described below.
A.  Individuals will be provided an outline of roles and responsibilities of both the agency and the individual.  The list will include the identification of risks inherent to the individual for each of the roles/responsibilities that can be assumed by the individual  to  enter  into  the  co-employment   relationship  with  the  agency. Individuals  can  use  this  tool  to  make  informed  decisions  about  selecting  the agency-with-choice option as well as selecting the individual roles and responsibilities they want to assume.
B.  Individuals will be required to develop a Contingency Plan as part of the person- centered service planning process.  The Contingency Plan allows for proactive planning to address and prevent potential gaps in the provision of services.  The Contingency  Plan  must  include  information  about  actions  that  the  individual and/or  individual’s  representative  should  take  to  report  any  gaps  and  what resources are available to the member, including on-call back-up caregivers and the  individual’s  informal  support  system,  to  resolve  unforeseeable  gaps  (e.g., regular caregiver illness, resignation without notice, transportation failure, etc.) within two hours.
C.  On a case-by-case basis, as determined by the Case Manager, the Managed Risk Agreement will be used to document risks and/or decisions made by the individual/individual’s representative that either increase (or don’t decrease) risks that the individual may encounter as a result of self-direction.
X.	Assurances
A.  The State assures that all eligible individuals, on a statewide basis, may elect the CFCO in a manner that provides such services and supports in the most integrated setting appropriate to the individual’s needs, and without regard to the individual’s age, type or nature of disability, severity of disability, or the form of home and community-based attendant services and supports that the individual requires to lead an independent life.
B. The State assures that individual representatives will not also serve as the paid caregiver of an individual receiving services and supports.    Individual representatives (including legal representatives) who wish to serve as paid caregivers must appoint another person, who is not a paid caregiver, to serve as a representative for the purpose of approving services and/or service hours during the service planning process.
C. The State assures that individuals receiving services through CFCO will not be precluded  from  receiving  other  home  and  community-based  long-term  care services and supports through other Medicaid State plan, waiver, grant or demonstration activities.
D.  The State assures to provide, or arrange for the provision of, a support system that meets all of the conditions for the services and supports provided under 42 CFR
441.555.

TN No.:  12-011
Supersedes	Approval Date
TN No.:  N/A

Effective Date: January 1, 2013

E.  The State assures CFCO services and supports are provided in accordance with the requirements of the Fair Labor Standards Act of 1938 and applicable Federal and State laws regarding the following:
i.	Withholding and payment of Federal and State income and payroll taxes. ii.	The provision of unemployment and workers compensation insurance.
iii.	Maintenance of general liability insurance. iv.	Occupational health and safety.
v.	Any other employment or tax related requirements
F.  The State assures necessary safeguards have been taken to protect the health and welfare of enrollees in CFCO, including adherence to section 1903(i) of the Act that Medicaid payment shall not be made for items or services furnished by individuals or entities excluded from participating in the Medicaid Program.
G.  The State assures for the first full 12 month period in which the State plan amendment is implemented, the State must maintain or exceed the level of State expenditures for home and community-based attendant services and supports provided under sections 1115, 1905(a), 1915, or otherwise under the Act, to individuals with disabilities or elderly individuals attributable to the preceding 12 month period.
H.  The State assures the collection and reporting of data as outlined in 42 CFR
441.580.

TN No.:  12-011
Supersedes	Approval Date
TN No.:  N/A

Effective Date: January 1, 2013