Georgia Medicaid Community First Choice (CFC): A Complete Guide to the Federal Section 1915(k) Framework and Georgia's Non-Adoption

::: hero

By Brevy Care Team · Last verified May 12, 2026

A complete guide to the federal Community First Choice (CFC) State Plan option under Section 1915(k) of the Social Security Act and Section 2401 of the Patient Protection and Affordable Care Act, how CFC provides a 6-percentage-point enhanced Federal Medical Assistance Percentage for attendant services and supports, how CFC requires statewide availability without waiting lists unlike Section 1915(c) HCBS waivers, how CFC requires person-centered planning, self-direction options, and comprehensive attendant services, how approximately 8 states have adopted CFC (California, Maryland, Montana, New York, Oregon, Texas, Washington, and Connecticut), why Georgia has not adopted CFC and instead operates attendant services through Section 1915(c) HCBS waivers (Community Care Services Program, Service Options Using Resources in a Community Environment, and Independent Care Waiver Program), and what the policy considerations and implications are for Georgia families seeking attendant services. :::

::: callout

Key takeaways

• Community First Choice (CFC) is a federal Medicaid State Plan option established by Section 2401 of the Patient Protection and Affordable Care Act and codified at Section 1915(k) of the Social Security Act.
• CFC provides a 6-percentage-point enhanced Federal Medical Assistance Percentage (FMAP) for attendant services and supports, reducing the state's share of CFC costs compared to standard Medicaid.
• CFC must be available statewide to all eligible beneficiaries without waiting lists, unlike Section 1915(c) HCBS waivers, which can impose enrollment limits and waiting lists.
• CFC requires person-centered service planning, self-direction options allowing beneficiaries to direct their own services, and comprehensive attendant services including assistance with activities of daily living, instrumental activities of daily living, and health-related tasks.
• CFC requires a Development and Implementation Council with majority membership of individuals receiving CFC services, their families, advocates, and other elderly and disabled stakeholders.
• A small number of states have adopted CFC as of 2024, including California, Maryland, Montana, New York, Oregon, Texas, Washington, and Connecticut.
• Georgia has NOT adopted CFC. Georgia's attendant services framework operates primarily through three Section 1915(c) HCBS waivers: Community Care Services Program (CCSP), Service Options Using Resources in a Community Environment (SOURCE), and Independent Care Waiver Program (ICWP).
• CFC requires states to maintain non-CFC HCBS expenditures at pre-CFC levels (the maintenance of effort requirement), which can be a deterrent for states facing budget pressures.
• Federal regulations at 42 CFR 441.500-.585 establish detailed CFC requirements including eligibility, covered services, person-centered planning, self-direction, quality assurance, and the Development and Implementation Council.
• If Georgia were to adopt CFC, the implications for Georgia families would include universal access to attendant services without waiting lists, statewide availability, enhanced self-direction, person-centered planning, and a structured stakeholder governance process. :::

What is Community First Choice and why does it matter

Community First Choice (CFC) is a federal Medicaid State Plan option that allows states to offer attendant services and supports to Medicaid beneficiaries who require institutional level of care. Unlike Section 1915(c) HCBS waivers, which can have enrollment limits and waiting lists, CFC is a State Plan benefit that must be available to all eligible beneficiaries statewide without waiting lists. States that adopt CFC receive a 6-percentage-point enhanced Federal Medical Assistance Percentage (FMAP) for CFC services.

CFC was created by Section 2401 of the Patient Protection and Affordable Care Act, providing states with a new authority to expand attendant services.

The legislative purpose of CFC was to expand access to community-based attendant services as an alternative to institutional care. Congress determined that Medicaid's institutional bias (the requirement that institutional services be covered while HCBS services are optional) discouraged community-based care. CFC was designed to reduce this bias by providing financial incentives (enhanced FMAP) and program requirements (statewideness, no waiting lists) that promote community-based attendant services.

A small number of states have adopted CFC as of 2024. Georgia has NOT adopted CFC. Georgia's attendant services framework operates primarily through three Section 1915(c) HCBS waivers: the Community Care Services Program (CCSP), the Service Options Using Resources in a Community Environment (SOURCE), and the Independent Care Waiver Program (ICWP).

Understanding the CFC framework is important for Georgia families even though Georgia has not adopted CFC, because (1) understanding the policy alternatives helps inform engagement with state policy discussions about LTSS reform, (2) Georgia families may move to or from CFC states and need to understand how the attendant services system differs across states, and (3) federal CFC policy may influence Georgia's future approach to attendant services.

Federal statutory foundation for CFC

Section 1915(k) of the Social Security Act

Section 1915(k) of the Social Security Act, codified at 42 USC 1396n(k), establishes the Community First Choice State Plan option. Section 1915(k) was added by Section 2401 of the Patient Protection and Affordable Care Act.

Key provisions of Section 1915(k) include:

Section 1915(k)(1) - Authority and enhanced FMAP

Section 1915(k)(1) authorizes states to elect to provide home and community-based attendant services and supports through the State Plan, and provides that states electing CFC will receive an enhanced FMAP of 6 percentage points above the standard FMAP for CFC services. The enhanced FMAP is the primary financial incentive for state CFC adoption.

Section 1915(k)(2) - Statewideness

Section 1915(k)(2) requires that CFC services be available throughout the state in a fair and equitable manner. This statewideness requirement is implemented at 42 CFR 441.510 and represents a key difference from Section 1915(c) waivers, which may have geographic limits.

Section 1915(k)(3) - Eligibility

Section 1915(k)(3) establishes that CFC is available to individuals who are eligible for Medicaid under the State Plan, who require institutional level of care, and who meet applicable income eligibility criteria (or are eligible under the state's institutional eligibility criteria).

Section 1915(k)(4) - Covered services

Section 1915(k)(4) establishes the covered services under CFC, including assistance with activities of daily living, instrumental activities of daily living, and health-related tasks, plus backup systems and voluntary training.

Section 1915(k)(5) - Person-centered planning

Section 1915(k)(5) requires person-centered service planning for CFC services.

Section 1915(k)(6) - Self-direction

Section 1915(k)(6) requires CFC to include self-direction options, allowing beneficiaries to direct their own services.

Section 1915(k)(7) - Development and Implementation Council

Section 1915(k)(7) requires states electing CFC to establish a Development and Implementation Council with majority membership of individuals receiving (or eligible to receive) CFC services, their families, advocates, and other stakeholders.

Section 1915(k)(9) - Maintenance of effort

Section 1915(k)(9) requires states electing CFC to maintain non-CFC HCBS expenditures at a level equal to or greater than the level in the year preceding CFC adoption. This MOE requirement is intended to prevent CFC adoption from being used to reduce overall HCBS spending.

Section 2401 of the Affordable Care Act

Section 2401 of the Patient Protection and Affordable Care Act (P.L. 111-148) is the statutory authority that added Section 1915(k) to the Social Security Act. The legislative history of Section 2401 reflects Congressional intent to expand community-based attendant services as an alternative to institutional care, supporting the broader ACA goals of expanding Medicaid coverage and improving access to care.

Relationship to other Section 1915 authorities

CFC under Section 1915(k) is one of several Section 1915 authorities for HCBS:

• Section 1915(c) authorizes HCBS waivers, which can have enrollment limits and waiting lists
• Section 1915(i) authorizes HCBS as a State Plan benefit (similar to CFC but with different requirements and eligibility)
• Section 1915(j) authorizes self-directed services
• Section 1915(k) authorizes Community First Choice

States may use different Section 1915 authorities for different populations or services. For example, a state might use Section 1915(c) waivers for individuals with developmental disabilities, Section 1915(i) for individuals with mental health conditions, and Section 1915(k) for older adults requiring nursing facility level of care.

Federal regulatory framework

42 CFR 441.500-.585

CMS issued a Final Rule for Community First Choice establishing the regulatory framework at 42 CFR 441.500-.585. Key regulatory provisions include:

42 CFR 441.500 - General provisions

42 CFR 441.500 establishes the general framework for CFC, including the state plan option, federal authority, and effective dates.

42 CFR 441.510 - Statewideness

42 CFR 441.510 implements the statewideness requirement of Section 1915(k)(2), requiring CFC services to be available throughout the state in a fair and equitable manner. States cannot limit CFC to specific geographic areas.

42 CFR 441.515 - Needs-based eligibility

42 CFR 441.515 establishes the needs-based eligibility criteria for CFC. Individuals are eligible for CFC if they:

1. Are eligible for Medicaid under the State Plan
2. Have income that does not exceed applicable income limits OR are eligible for nursing facility level of care under the state's institutional eligibility criteria
3. Require institutional level of care (nursing facility, ICF/IID, or hospital level of care)
4. Need assistance with one or more activities of daily living, instrumental activities of daily living, or health-related tasks

42 CFR 441.520 - Covered services

42 CFR 441.520 establishes the required and optional covered services under CFC. Required services include:

1. Attendant services to assist with:
   • Activities of daily living (eating, toileting, grooming, dressing, bathing, transferring)
   • Instrumental activities of daily living (meal preparation, money management, shopping, transportation, household chores, telephone communication)
   • Health-related tasks (under nurse delegation if state law permits)
2. Backup systems to ensure continuity of services in case attendant services are unavailable
3. Voluntary training on how to select, manage, and dismiss attendants

Optional services that states may include in their CFC programs:

1. Transition costs (one-time costs to move from institutional to community settings, such as security deposits, household items, and moving expenses)
2. Items that enhance independence (e.g., microwave to enable independent meal preparation)

42 CFR 441.525 - Person-centered service plan

42 CFR 441.525 requires CFC services to be furnished according to a person-centered service plan that:

1. Reflects the beneficiary's preferences, goals, and needs
2. Identifies risks and includes strategies to address them
3. Is developed through a person-centered planning process led by the beneficiary
4. Includes the beneficiary's family or representative as appropriate
5. Is reviewed and revised at least annually or when circumstances change

42 CFR 441.530 - HCBS settings rule

42 CFR 441.530 (the HCBS settings rule) requires CFC services to be furnished in settings that meet federal HCBS settings requirements. HCBS settings must be integrated in the community, support full access to the greater community, ensure the individual receives services in the community to the same degree as individuals not receiving Medicaid HCBS, optimize but not regiment individual initiative and autonomy, and facilitate individual choice.

42 CFR 441.535 - Development and Implementation Council

42 CFR 441.535 requires states adopting CFC to establish a Development and Implementation Council. The Council must:

1. Have majority membership of individuals receiving (or eligible to receive) CFC services, their families, advocates, and other elderly and disabled stakeholders
2. Provide input on CFC program design, implementation, evaluation, and ongoing operations
3. Meet regularly to provide ongoing input

The Development and Implementation Council is one of the unique features of CFC, ensuring that beneficiaries and their representatives have a structured role in program governance.

42 CFR 441.540 - Self-direction

42 CFR 441.540 requires CFC to include self-direction options. Self-direction may include:

1. Hiring and managing attendants (including family members in many circumstances)
2. Setting attendant schedules
3. Managing the care budget within state-approved limits

Self-direction is a core feature of CFC, reflecting the philosophy that beneficiaries should have control over their services.

42 CFR 441.555 - Quality assurance

42 CFR 441.555 requires CFC programs to include quality assurance, including discovery (identifying issues), remediation (addressing identified issues), and continuous improvement (preventing future issues).

42 CFR 441.565 - Individual rights

42 CFR 441.565 requires CFC programs to protect individual rights, including the right to choose providers, the right to be involved in decision-making, the right to receive services in the community, and the right to grievance and appeal.

42 CFR 441.575 - Cost-sharing

42 CFR 441.575 allows states to impose limited cost-sharing on CFC services, subject to general Medicaid cost-sharing rules. Cost-sharing must not be a barrier to access.

42 CFR 441.580 - Financial eligibility

42 CFR 441.580 establishes financial eligibility requirements for CFC, generally aligning with state Medicaid eligibility rules with the special provisions for individuals meeting income eligibility thresholds and individuals eligible under institutional eligibility criteria.

42 CFR 441.585 - Maintenance of effort

42 CFR 441.585 implements the MOE requirement of Section 1915(k)(9), requiring states adopting CFC to maintain their non-CFC HCBS expenditures at a level equal to or greater than expenditures in the year prior to CFC adoption. The MOE requirement is intended to prevent CFC adoption from being used to reduce overall HCBS spending.

State CFC adoption

A small number of states have adopted Community First Choice:

California

California adopted CFC as part of the Coordinated Care Initiative. California's CFC program covers attendant services for Medi-Cal beneficiaries who meet needs-based eligibility. California has the largest CFC program by enrollment, reflecting California's large population and extensive HCBS infrastructure.

Maryland

Maryland adopted CFC. Maryland's CFC program is integrated with the Medical Assistance Personal Care program and other LTSS programs. Maryland's CFC program serves older adults and adults with disabilities.

Montana

Montana adopted CFC. Montana's CFC program serves individuals with disabilities and older adults requiring nursing facility level of care.

New York

New York adopted CFC. New York's CFC program covers attendant services as part of the state's comprehensive LTSS framework, which includes Managed Long-Term Care (MLTC) and other programs.

Oregon

Oregon adopted CFC. Oregon's CFC program is part of the state's Coordinated Care Organization (CCO) framework.

Texas

Texas adopted CFC. Texas's CFC program is integrated with the STAR+PLUS managed care program. Texas has a large CFC program by enrollment.

Washington

Washington adopted CFC. Washington's CFC program serves individuals requiring nursing facility level of care.

Connecticut

Connecticut adopted CFC. Connecticut's CFC program is part of the state's comprehensive LTSS framework.

The relatively limited adoption (8 states out of 50) reflects the complexity of CFC implementation and the policy trade-offs involved. Several other states have considered CFC adoption but have not implemented it.

Why states adopt CFC

States adopt CFC for several reasons:

Enhanced FMAP

The 6-percentage-point enhanced FMAP provides significant federal financial participation. For states with substantial attendant services expenditures, the financial benefit can be significant. The enhanced FMAP applies indefinitely (it is not time-limited).

Reducing waiting lists

CFC eliminates waiting lists for attendant services, providing access to all eligible beneficiaries. For states with substantial waiver waiting lists, CFC is a tool for expanding access.

Statewideness

CFC ensures statewide availability, eliminating geographic disparities in HCBS access that may exist under Section 1915(c) waivers.

Self-direction

CFC requires self-direction options, supporting beneficiary autonomy and family caregiver involvement. Family members can often be paid as attendants under CFC self-direction (subject to state policy choices, such as whether spouses or legally responsible relatives can be paid).

Person-centered planning

CFC requires person-centered planning, supporting beneficiary-driven care plans that reflect individual preferences and goals.

Stakeholder governance

The Development and Implementation Council provides a structured forum for beneficiary, family, and advocate input on program operations, supporting ongoing program improvement.

Rebalancing

CFC supports state rebalancing efforts by expanding access to community-based attendant services as an alternative to institutional care.

Why states do not adopt CFC

States may decline to adopt CFC for several reasons:

Maintenance of effort

The MOE requirement prevents states from using CFC adoption to reduce overall HCBS spending. For states facing budget pressures, the MOE requirement may be a deterrent.

State share of CFC costs

While CFC has an enhanced FMAP, states still pay a share of CFC costs. The state share of expanded CFC services represents new state spending compared to limited Section 1915(c) waiver enrollment.

Statewide availability without waiting lists

The requirement for statewide availability without waiting lists means states cannot manage CFC enrollment through waiver-style slot allocation. This eliminates a key cost control mechanism states use for Section 1915(c) waivers.

Implementation complexity

CFC implementation requires substantial state Medicaid agency capacity, including developing eligibility processes, payment systems, quality assurance, the Development and Implementation Council, and other operational infrastructure.

Existing HCBS waiver infrastructure

States with well-developed Section 1915(c) waiver infrastructure may prefer to continue with waivers rather than transition to CFC. The transition would require significant system changes.

Stakeholder dynamics

Different stakeholders (providers, beneficiaries, advocates, state officials) may have varying views on CFC adoption, complicating the political process for adoption. Provider associations sometimes have concerns about CFC's self-direction options (which can divert services from agency providers to self-directed attendants), and beneficiary advocacy groups generally support CFC but may differ on specific program design choices.

Georgia's attendant services framework

Georgia does not operate Community First Choice. Georgia's attendant services framework operates through several authorities:

Section 1915(c) HCBS waivers

Georgia operates five Section 1915(c) HCBS waivers, three of which cover attendant services for older adults and adults with physical disabilities:

Community Care Services Program (CCSP)

CCSP serves older adults (age 65 and over) and adults with disabilities (age 18 and over) who require nursing facility level of care. CCSP provides personal care services, homemaker services, home delivered meals, adult day health, alternative living services, emergency response services, and other HCBS. CCSP has an enrollment limit set by the state, and a waiting list exists for new enrollees.

Service Options Using Resources in a Community Environment (SOURCE)

SOURCE serves older adults and adults with disabilities who require nursing facility level of care, with enhanced case management. SOURCE includes the CCSP services plus specialized case management agencies that coordinate care for enrollees with more complex needs. SOURCE also has enrollment limits.

Independent Care Waiver Program (ICWP)

ICWP serves adults (age 21 to 64) with severe physical disabilities who require nursing facility or hospital level of care. ICWP provides personal support services, skilled nursing, behavioral support, and other services. ICWP serves a smaller population than CCSP/SOURCE.

State Plan personal care services

Georgia's State Plan provides limited personal care services, but these are not equivalent to the comprehensive CFC framework. State Plan personal care in Georgia is typically delivered through skilled home health agencies and is more limited in scope than CFC attendant services.

Self-direction options

Georgia has limited self-direction options. Some HCBS waivers allow for limited participant-directed services, but Georgia does not have a comprehensive self-direction framework like the CFC self-direction requirement.

Why Georgia has not adopted CFC

Georgia has not adopted CFC. Several factors have contributed to this:

MOE concerns

The maintenance of effort requirement would require Georgia to maintain its non-CFC HCBS expenditures at the pre-CFC level. For Georgia, with HCBS waivers facing budget pressures and waiting lists, the MOE requirement may be a deterrent.

State share of expanded services

While CFC has an enhanced FMAP, Georgia would still pay a share of expanded CFC services. The state share of expanded services represents new state spending compared to the limited Section 1915(c) waiver enrollment.

Statewide availability commitment

The requirement for statewide availability without waiting lists is a significant commitment. Georgia currently uses waiting lists to manage HCBS enrollment within budget constraints. Eliminating waiting lists for attendant services would require new state funding to serve the additional population that would become eligible.

Existing waiver infrastructure

Georgia has invested in CCSP, SOURCE, and ICWP infrastructure. Transitioning to CFC would require significant system changes, including new eligibility processes, payment systems, quality assurance frameworks, and the establishment of the Development and Implementation Council.

Legislative direction

The Georgia General Assembly has not directed DCH to implement CFC. State legislative authority would typically be required for major LTSS reforms.

Other Medicaid priorities

Recent Georgia Medicaid reform efforts have focused on Pathways to Coverage, postpartum coverage extension, and other priorities. CFC has not been a top-tier reform priority.

Comparison: CFC vs Georgia's HCBS waivers

CFC and Georgia's HCBS waivers differ in several important ways:

::: table caption="CFC vs. Georgia HCBS Waivers Comparison"

What CFC adoption would mean for Georgia

If Georgia were to adopt CFC, the implications for Georgia families would include:

Universal access for eligible beneficiaries

CFC would provide universal access to attendant services for all Medicaid beneficiaries meeting needs-based eligibility, eliminating waiver waiting lists for attendant services. This would be a significant change from the current waiver framework, where CCSP, SOURCE, and ICWP all have waiting lists.

Statewide availability

CFC would be available statewide, requiring the state to ensure provider capacity across all geographic areas, including rural areas. The state would need to address rural provider shortages that currently limit access to HCBS in some parts of Georgia.

Enhanced self-direction

CFC would provide comprehensive self-direction options, allowing beneficiaries (and family caregivers) more control over services. Self-direction would allow beneficiaries to hire and manage their own attendants, including family members in many circumstances (subject to state policy choices).

Person-centered planning

CFC would require person-centered planning, supporting beneficiary-driven care plans. While CCSP, SOURCE, and ICWP already include person-centered planning requirements under 42 CFR 441.301, CFC's requirements may be more comprehensive.

Development and Implementation Council

CFC would establish a Development and Implementation Council with majority beneficiary/family/advocate membership, providing a formal channel for stakeholder input. This would be a new governance structure for Georgia's LTSS system.

Enhanced FMAP

Georgia would receive a 6-percentage-point enhanced FMAP for CFC services, reducing the state share. The state share savings could be used to expand services or for other purposes.

MOE requirements

Georgia would need to maintain non-CFC HCBS expenditures at pre-CFC levels. This would prevent CFC adoption from being used to reduce HCBS waiver spending.

Worked examples

Example 1: Margaret, 78, Macon, CCSP enrollee

Margaret is a 78-year-old widow living in Macon, currently enrolled in the Community Care Services Program (CCSP). She receives 25 hours per week of personal care services, home-delivered meals, and emergency response services through CCSP. Before being enrolled in CCSP, Margaret was on the CCSP waiting list for 14 months. During that time, she relied on her adult daughter for caregiving support.

Under Georgia's current framework, Margaret's CCSP services are coordinated by her CCSP case manager and paid by Georgia Medicaid on a fee-for-service basis at the standard FMAP.

Under a hypothetical CFC implementation in Georgia, Margaret would receive her attendant services as a CFC State Plan benefit rather than as a CCSP waiver service. She would not have faced the 14-month waiting list because CFC has no waiting lists. Her services could be self-directed if she chose, allowing her to hire her own attendants (possibly including family members) and set her own schedule. Federal financial participation would be at Georgia's standard FMAP plus 6 percentage points, reducing the state share.

This example illustrates key advantages of CFC: elimination of waiting lists, enhanced self-direction, and higher federal financial participation.

Example 2: Henry, 50, Atlanta, ICWP enrollee with physical disability

Henry is a 50-year-old man in Atlanta who acquired quadriplegia 8 years ago following a spinal cord injury. He receives personal support services, skilled nursing, and other services through the Independent Care Waiver Program (ICWP). Henry waited 18 months for an ICWP slot before being enrolled.

Under Georgia's current framework, Henry's ICWP services are coordinated by his ICWP case manager and paid by Georgia Medicaid at the standard FMAP. ICWP has a smaller enrollment than CCSP/SOURCE, reflecting the smaller eligible population (adults with severe physical disabilities aged 21 to 64).

Under a hypothetical CFC implementation, Henry would receive attendant services as a CFC State Plan benefit, with self-direction allowing him to hire and direct his own attendants. Self-direction is particularly important for individuals with quadriplegia who need very specific care techniques that require attendant training. Henry would not have faced the 18-month waiting list, and he would have more control over his care.

Example 3: Sarah, 35, Savannah, daughter providing care

Sarah is 35 years old and lives with her elderly mother in Savannah. Sarah's mother is 82 years old and has dementia. Sarah provides full-time care to her mother. Sarah's mother receives some CCSP services (12 hours per week of personal care), but Sarah provides the bulk of care without compensation.

Sarah works part-time to support herself and her mother but has had to reduce her work hours to provide care. Sarah's family situation reflects a common pattern: family caregivers (often adult daughters) provide the majority of LTSS in the United States, with formal services supplementing rather than replacing family care.

Under Georgia's current framework, Sarah's caregiving is largely unpaid. CCSP has some structured family caregiving provisions that may allow payment for caregiving in limited circumstances (typically requiring the family caregiver to be hired through a CCSP-contracted agency), but the framework is limited.

Under a hypothetical CFC implementation, Sarah could potentially be hired as her mother's attendant under CFC's self-direction option. This would provide Sarah with compensation for her caregiving work and could allow her to continue providing care to her mother while maintaining financial stability. CFC's self-direction provisions allow family caregivers to be paid in many circumstances, with certain restrictions (such as spouses being prohibited as paid caregivers in some states, depending on state policy choices).

This example illustrates a major potential benefit of CFC for Georgia families: the ability for family caregivers to be paid for their caregiving work under self-direction.

Example 4: Robert, 65, Augusta, dual eligible

Robert is a 65-year-old dual eligible (Medicare and Medicaid) in Augusta. He has chronic obstructive pulmonary disease and limited mobility. He receives Medicare for most acute and primary care, and Medicaid covers Medicare cost-sharing (under the Qualified Medicare Beneficiary program) plus HCBS waiver services (SOURCE).

Under Georgia's current framework, Robert's SOURCE services are coordinated by his SOURCE case manager and paid by Georgia Medicaid at the standard FMAP. His Medicare services are coordinated separately.

Under a hypothetical CFC implementation, Robert would receive attendant services as CFC State Plan benefits. His Medicare and CFC services would still need to be coordinated, but CFC would provide additional services beyond what is currently available through Medicare. Medicare does not generally cover long-term attendant services, so CFC fills an important gap for dual eligibles.

Example 5: Linda, 28, Athens, ineligible due to no waiver slot

Linda is 28 years old with multiple sclerosis. She has progressive disability that has limited her ability to work and live independently. She needs attendant services to remain in her own home. She applied for ICWP 9 months ago and is on the waiting list. While on the waiting list, she relies on family caregivers and self-pay for some services.

Under Georgia's current framework, Linda will receive ICWP services when a slot becomes available, but the wait may be substantial. The ICWP waiting list reflects the limited number of waiver slots authorized by the state legislature.

Under a hypothetical CFC implementation, Linda would receive attendant services immediately upon meeting the needs-based eligibility criteria, with no waiting list. CFC is an entitlement (all eligible beneficiaries must be served) rather than a capped benefit. This example illustrates the most significant advantage of CFC for individuals who currently face waiver waiting lists: universal entitlement without waiting lists.

Example 6: Frances, 85, Columbus, seeking statewide access

Frances is 85 years old and lives in a rural area near Columbus. She needs attendant services to remain in her own home. She applied for CCSP 6 months ago and is on the waiting list. She is also concerned about service availability in her rural area: even when she gets a CCSP slot, she may face limited provider availability.

Under Georgia's current framework, CCSP and SOURCE are theoretically available statewide, but rural provider capacity is limited. When Frances eventually gets a CCSP slot, she may face limited provider availability in her rural area, which could affect the quality and reliability of her services.

Under a hypothetical CFC implementation, CFC would be required to be available statewide. The state would need to ensure provider capacity in rural areas, possibly through provider recruitment, training, and rate adjustments. CFC's self-direction option would also allow Frances to hire her own attendants (e.g., neighbors or family members who could be trained and paid as attendants), expanding the pool of potential providers.

This example illustrates how CFC's statewideness requirement could address rural service access challenges that currently affect Georgia's HCBS waivers.

Frequently asked questions

::: accordion

What is Community First Choice (CFC)?

Community First Choice (CFC) is a federal Medicaid State Plan option that allows states to offer attendant services and supports to Medicaid beneficiaries who require institutional level of care. CFC was established by Section 2401 of the Patient Protection and Affordable Care Act and is codified at Section 1915(k) of the Social Security Act. Unlike Section 1915(c) HCBS waivers, CFC is a State Plan benefit that must be available to all eligible beneficiaries statewide without waiting lists.

Does Georgia have CFC?

No. Georgia has not adopted Community First Choice. Georgia's attendant services framework operates primarily through three Section 1915(c) HCBS waivers: the Community Care Services Program (CCSP), the Service Options Using Resources in a Community Environment (SOURCE), and the Independent Care Waiver Program (ICWP). All three waivers have enrollment limits and waiting lists.

How many states have CFC?

A small number of states have adopted Community First Choice, including California, Maryland, Montana, New York, Oregon, Texas, Washington, and Connecticut. The relatively limited adoption reflects the complexity of CFC implementation and the policy trade-offs involved.

What is the enhanced FMAP for CFC?

States that adopt CFC receive a 6-percentage-point increase in the Federal Medical Assistance Percentage (FMAP) for CFC services, reducing the state's share of those costs. The enhanced FMAP is the primary financial incentive for state CFC adoption.

Who is eligible for CFC?

Under federal regulations at 42 CFR 441.515, individuals are eligible for CFC if they (1) are eligible for Medicaid under the State Plan, (2) meet applicable income eligibility requirements OR are eligible for nursing facility level of care under the state's institutional eligibility criteria, (3) require institutional level of care (nursing facility, ICF/IID, or hospital level of care), and (4) need assistance with one or more activities of daily living, instrumental activities of daily living, or health-related tasks.

What services does CFC cover?

CFC covers attendant services to assist with activities of daily living (eating, toileting, grooming, dressing, bathing, transferring), instrumental activities of daily living (meal preparation, money management, shopping, transportation, household chores, telephone communication), and health-related tasks (under nurse delegation if state law permits). CFC also covers backup systems and voluntary training on how to select, manage, and dismiss attendants. States may also include optional services such as transition costs and items that enhance independence.

What is self-direction under CFC?

Self-direction is a required feature of CFC under 42 CFR 441.540. Self-direction allows beneficiaries to direct their own services, including hiring and managing attendants (often including family members), setting attendant schedules, and managing the care budget within state-approved limits. Self-direction reflects the philosophy that beneficiaries should have control over their services.

Can family members be paid as attendants under CFC?

In many circumstances, yes. CFC's self-direction option allows beneficiaries to hire family members as attendants. Specific policies vary by state. Some states prohibit spouses or legally responsible relatives from being paid as attendants, while other states allow it. Federal regulations provide states flexibility in setting these policies.

What is the Development and Implementation Council?

Under 42 CFR 441.535, states adopting CFC must establish a Development and Implementation Council to guide CFC program design and implementation. The Council must have majority membership of individuals receiving (or eligible to receive) CFC services, their families, advocates, and other elderly and disabled stakeholders. The Council provides input on CFC program design, implementation, evaluation, and ongoing operations. The Council is one of the unique features of CFC, ensuring that beneficiaries have a structured role in program governance.

What is the maintenance of effort requirement for CFC?

Under 42 CFR 441.585, states adopting CFC must maintain their non-CFC HCBS expenditures at a level equal to or greater than expenditures in the year prior to CFC adoption. The MOE requirement is intended to prevent CFC adoption from being used to reduce overall HCBS spending. The MOE requirement is one of the deterrents to state CFC adoption.

How does CFC differ from Section 1915(c) HCBS waivers?

CFC and Section 1915(c) waivers differ in several important ways. CFC is a State Plan benefit while Section 1915(c) is a waiver. CFC must be available statewide without waiting lists while Section 1915(c) can have enrollment limits and waiting lists. CFC has an enhanced FMAP (standard plus 6 percentage points) while Section 1915(c) has standard FMAP. CFC requires self-direction while Section 1915(c) makes self-direction optional. CFC requires a Development and Implementation Council while Section 1915(c) does not. CFC has maintenance of effort requirements while Section 1915(c) does not.

Why has Georgia not adopted CFC?

Georgia has not adopted CFC for several reasons including (1) the maintenance of effort requirement would lock in current HCBS expenditures; (2) statewide availability without waiting lists would require new state spending to serve the expanded population; (3) the state share of expanded CFC services represents new state spending; (4) existing CCSP, SOURCE, and ICWP infrastructure would need significant system changes; (5) the Georgia General Assembly has not directed DCH to implement CFC; and (6) recent Medicaid reform priorities have focused on other initiatives such as Pathways to Coverage.

Would CFC eliminate waiting lists for HCBS waivers in Georgia?

CFC would eliminate waiting lists for attendant services covered under CFC. However, CFC does not cover all HCBS services that are currently covered under Georgia's HCBS waivers. For example, CFC does not cover adult day services, residential supports, or developmental disability services. These services would continue to be available through Section 1915(c) waivers (CCSP, SOURCE, ICWP, NOW, COMP), and waiting lists for those services could continue.

How would CFC implementation work in Georgia if it were adopted?

If Georgia were to adopt CFC, the typical implementation process would include: (1) policy analysis and stakeholder engagement; (2) establishment of the Development and Implementation Council with majority beneficiary/family/advocate membership; (3) program design including covered services, eligibility processes, payment methodology, and quality assurance; (4) State Plan amendment filing with CMS; (5) CMS approval; and (6) implementation including provider enrollment, beneficiary outreach, and system development. The total timeline from initial decision to full implementation is typically 1-3 years.

How does CFC interact with Medicare for dual eligibles?

For dual eligible beneficiaries (those eligible for both Medicare and Medicaid), Medicare is the primary payer for medical services. CFC fills an important gap because Medicare does not generally cover long-term attendant services. CFC services are coordinated with Medicare services through the state's standard coordination of benefits processes.

What is the HCBS settings rule and how does it apply to CFC?

The HCBS settings rule, codified at 42 CFR 441.530, establishes federal requirements for HCBS settings. The rule requires HCBS settings to be integrated in the community, support full access to the greater community, ensure the individual receives services in the community to the same degree as individuals not receiving Medicaid HCBS, optimize but not regiment individual initiative and autonomy, and facilitate individual choice. The HCBS settings rule applies to all HCBS, including CFC services. CFC programs must ensure that settings used for CFC services comply with the settings rule.

What is person-centered planning under CFC?

Under 42 CFR 441.525, CFC services must be furnished according to a person-centered service plan. The plan must reflect the beneficiary's preferences, goals, and needs; identify risks and include strategies to address them; be developed through a person-centered planning process led by the beneficiary; include the beneficiary's family or representative as appropriate; and be reviewed and revised at least annually or when circumstances change.

How does CFC support rebalancing from institutional to community-based care?

CFC supports rebalancing by expanding access to community-based attendant services as an alternative to institutional care. By providing universal access to attendant services for eligible beneficiaries, CFC reduces barriers to community-based care. The enhanced FMAP provides financial incentive for states to expand community-based services rather than relying on more expensive institutional care.

What are the quality requirements for CFC?

Under 42 CFR 441.555, CFC programs must include quality assurance, including discovery (identifying issues), remediation (addressing identified issues), and continuous improvement (preventing future issues). States must have processes for monitoring service quality, addressing complaints and incidents, and improving program performance over time.

What rights do beneficiaries have under CFC?

Under 42 CFR 441.565, CFC programs must protect individual rights, including the right to choose providers, the right to be involved in decision-making, the right to receive services in the community, and the right to grievance and appeal. These rights are similar to rights under other Medicaid programs but emphasize the community-based and beneficiary-directed nature of CFC.

How do I find out more about Georgia's attendant services options?

For information about Georgia's attendant services options, contact (1) the Department of Community Health Medicaid Member Services for general Medicaid information; (2) the Division of Aging Services Aging and Disability Resource Connection (ADRC) for information about HCBS waivers and aging services; (3) your local Area Agency on Aging for information about CCSP and SOURCE; or (4) Brevy's other Georgia Medicaid guides for detailed information about LTSS, HCBS waivers, and related topics.

:::

Contacts and resources

::: cta

Get help with Georgia Medicaid attendant services

If you need help understanding Georgia Medicaid attendant services options, the following contacts and resources are available:

• DCH Medicaid Member Services: Contact Georgia's Department of Community Health for general Medicaid information and member services
• DAS Aging and Disability Resource Connection (ADRC): Division of Aging Services entry point for HCBS waiver information for older adults and adults with disabilities
• DCH HCBS Waiver Unit: Contact through DCH main number for waiver-specific information
• DBHDD Customer Service: Department of Behavioral Health and Developmental Disabilities, for NOW and COMP waiver information
• DFCS Customer Service: Division of Family and Children Services, the state agency that processes Medicaid applications
• Georgia Gateway: gateway.ga.gov (online portal for Medicaid applications, renewals, and case management)
• AARP Georgia: Advocacy and education for older adults in Georgia
• Georgia Long-Term Care Ombudsman: Advocacy for residents of long-term care facilities
• Atlanta Regional Commission Area Agency on Aging: Local area agency on aging for metro Atlanta
• Georgia Legal Services Program: Legal assistance for low-income individuals
• 211 Georgia: 2-1-1 (statewide information and referral service)
• CMS Region IV: Contact through CMS Region IV main number for federal Medicaid oversight matters in the Southeast
• National Resource Center for Participant-Directed Services: National resource on self-direction and participant-directed services
• ADvancing States (formerly NASUAD): National association supporting state aging and disability agencies
• National Council on Aging: National advocacy organization for older adults :::

Final notes

Community First Choice is a federal Medicaid State Plan option under Section 1915(k) of the Social Security Act that provides states with a 6-percentage-point enhanced Federal Medical Assistance Percentage for attendant services and supports, requires statewide availability without waiting lists, and includes person-centered planning, self-direction, and a Development and Implementation Council. A small number of states have adopted CFC. Georgia has not adopted CFC and instead operates attendant services through Section 1915(c) HCBS waivers (CCSP, SOURCE, and ICWP). Understanding the CFC framework helps Georgia families understand the policy alternatives for attendant services and engage with state policy discussions about LTSS reform.

This article is part of a comprehensive series on Georgia Medicaid published by Brevy. We are committed to providing accurate, up-to-date information for Georgia families navigating Medicaid eligibility, enrollment, benefits, and appeals. Find personalized help navigating Georgia Medicaid attendant services at brevy.com.

This article is for informational purposes only and does not constitute legal, financial, or medical advice. Brevy is a digital ally, not a substitute for professional legal or financial counsel. Federal and state Medicaid rules change frequently. For questions specific to your situation, consult with the Georgia Department of Community Health, the Division of Family and Children Services, the Division of Aging Services, or a qualified attorney or financial advisor.