Georgia Money Follows the Person (2026): Nursing Facility Transitions

If a parent or relative is living in a Georgia nursing facility and wants to come home, Money Follows the Person (MFP) is the Medicaid program built to make that move possible. It helps people leave nursing facilities, intermediate care facilities, and long-term hospitals for their own home, a family member's home, or a small community residence, with the Medicaid supports following them out the door. Georgia runs MFP through the Department of Community Health and the Department of Behavioral Health and Developmental Disabilities, pairing each transition with a home and community-based services waiver (CCSP, SOURCE, ICWP, NOW, or COMP).

Key takeaways

• Money Follows the Person is a federal Medicaid demonstration program created by the Deficit Reduction Act of 2005 at Section 6071. It provides enhanced federal matching funds for the first 12 months of community-based services following a qualifying transition from a Medicaid-certified institution back to a home setting. The enhanced match offsets the higher up-front costs of transition planning, pre-discharge supplemental services, housing setup, and intensive coordination during the first year in the community.
• The federal authority traces directly to Olmstead v. L.C., 527 U.S. 581 (1999), the U.S. Supreme Court decision originating in Georgia in which Lois Curtis and Elaine Wilson sued the state for confining them at Georgia Regional Hospital Atlanta after their treatment teams had concluded that community placement was appropriate. Justice Ginsburg's majority opinion held that unnecessary institutionalization of people with disabilities is a form of discrimination under Title II of the Americans with Disabilities Act of 1990, and that states must provide services in the most integrated setting appropriate to the individual's needs. Money Follows the Person is the federal government's principal financing tool for implementing that integration mandate.
• To qualify for an MFP transition in Georgia, a person must have lived in a Medicaid-certified nursing facility, an intermediate care facility for individuals with intellectual disabilities, or a long-term inpatient hospital for the federally required minimum stay, with Medicaid paying for at least one day of the qualifying stay. The Affordable Care Act of 2010 at Section 2403 significantly reduced the institutional stay requirement, opening the door to transition planning much earlier than was previously possible.
• Qualified community residences include the person's own home, a family member's home (including a son's or daughter's home, a sibling's home, or any other relative's home where the person is welcome to live), or a small group residence meeting the federal qualified community residence definition. Larger assisted living facilities, traditional personal care homes, and congregate care settings are not qualified MFP residences, and a transition into one of those settings is not eligible for MFP supplemental services or the enhanced federal match.
• Georgia operates Money Follows the Person through the Department of Community Health Division of Medical Assistance and the Department of Behavioral Health and Developmental Disabilities, with transition coordination flowing through Aging and Disability Resource Connection offices, Area Agencies on Aging, and contracted transition agencies. The MFP transition runs in tandem with one of Georgia's 1915(c) home and community-based services waivers: CCSP or SOURCE for elderly individuals and adults with physical disabilities, ICWP for adults with traumatic brain injury, spinal cord injury, or complex medical needs, and NOW or COMP for adults with intellectual or developmental disabilities.
• MFP supplemental services pay for one-time pre-transition costs that traditional Medicaid does not cover. These include security deposits, the first month of rent, utility activation, household furniture and basic kitchen supplies, durable medical equipment not otherwise covered, ramps and grab bars, accessible bathroom modifications, an initial supply of groceries, and a personal emergency response system. These costs are capped per individual and are paid in addition to the regular waiver services that begin the day the person walks back through the front door of their new home.

What Money Follows the Person Actually Is

Money Follows the Person is a federal Medicaid demonstration program that funds the transition of people from institutional long-term care back to community settings. The program was created by Section 6071 of the Deficit Reduction Act of 2005, which Congress passed in February 2006. The original statutory purpose, in the language of Section 6071(b), was to "rebalance" state long-term care systems away from institutional placement and toward home and community-based services.

The mechanism is financial. Under traditional Medicaid, the federal government reimburses Georgia for a set share of the cost of covered services through the federal medical assistance percentage, with the state paying the remaining share. For a person transitioning out of an institution under Money Follows the Person, that federal share rises for the first 12 months of community-based services. The state saves money on every dollar of MFP-eligible service it provides during the demonstration period, and that savings is one of the principal incentives for the state to invest in transition planning, pre-discharge supports, and intensive first-year coordination.

The federal authority has been extended and modified several times since 2006. The Affordable Care Act of 2010 at Section 2403 reduced the qualifying institutional stay from 6 months to 90 days, expanded the categories of qualifying institutions, and authorized expanded transition supports. The Bipartisan Budget Act of 2018, the Medicaid Extenders Act of 2019, the Consolidated Appropriations Act of 2021, and the Consolidated Appropriations Act, 2023 each provided additional extensions and funding. The 2023 reauthorization, the Consolidated Appropriations Act, 2023 (Public Law 117-328) at Section 5114, extended Money Follows the Person at $450 million per year for each of federal fiscal years 2024 through 2027, funding the program through September 30, 2027, and also extended the related home and community-based services spousal-impoverishment protections through that same date.

The program has been remarkably successful at the national level, with CMS reporting substantial participation across the majority of states over the demonstration's lifespan. Georgia is one of the states that has continuously operated an MFP program since the original 2007 implementation cycle.

The Olmstead Origin Story

Money Follows the Person did not appear in a policy vacuum. The federal program is the direct legislative response to the U.S. Supreme Court's decision in Olmstead v. L.C., 527 U.S. 581 (1999), and it is worth understanding the Olmstead case in detail because the decision originated in Georgia and continues to shape every MFP transition in the state.

Lois Curtis was a Black woman with intellectual disability and schizophrenia. Elaine Wilson was a white woman with intellectual disability and a personality disorder. Both had been admitted to Georgia Regional Hospital Atlanta, a state psychiatric institution operated by what is now the Department of Behavioral Health and Developmental Disabilities. Their treatment teams at Georgia Regional concluded over the course of their hospitalizations that they no longer required institutional placement and were appropriate for community-based services. Despite those clinical recommendations, both women remained at Georgia Regional Hospital for years (Curtis for several years, Wilson for more than a decade) because the state had not made community placement available.

Curtis and Wilson, with the assistance of the Atlanta Legal Aid Society and attorney Sue Jamieson, sued the state of Georgia in federal court under Title II of the Americans with Disabilities Act of 1990. The state of Georgia was represented by Tommy Olmstead, then the Commissioner of the Department of Human Resources, which is how the case came to bear his name. The case made its way to the U.S. Supreme Court, which issued its decision on June 22, 1999.

Justice Ruth Bader Ginsburg, writing for a 6-3 majority, held that unjustified institutional isolation of people with disabilities is a form of discrimination prohibited by Title II of the ADA. The decision established that states must provide community-based services for people with disabilities when (a) the state's treatment professionals determine that community placement is appropriate, (b) the affected individual does not oppose community placement, and (c) the placement can be reasonably accommodated taking into account the resources available to the state and the needs of others receiving state-supported disability services.

The Olmstead decision created the integration mandate that drives MFP. States must take affirmative steps to identify institutionalized people who could live in the community, must develop plans to transition them, and must build the community-based service capacity required to make those transitions possible. Money Follows the Person is the principal federal financing tool that pays for the work the Olmstead decision requires.

Lois Curtis was released from Georgia Regional Hospital to a community setting after the decision and lived in Georgia for the rest of her life. She became an artist whose paintings hang in the Smithsonian and met with President Barack Obama at the White House on the Olmstead anniversary in 2011. She died in 2022. Elaine Wilson died in 2004. Their case continues to be the controlling federal authority on community integration for people with disabilities, and every MFP transition in Georgia is, in a meaningful sense, a piece of the answer to the question the Olmstead plaintiffs raised more than 25 years ago.

How Georgia Operates the Program

Georgia's Money Follows the Person demonstration has been continuously operational since the state's original CMS-approved operational protocol took effect in 2007. The lead state agency is the Department of Community Health, which administers Georgia Medicaid through its Division of Medical Assistance. The DBHDD plays a co-lead role for transitions out of intermediate care facilities for individuals with intellectual disabilities and out of the state's psychiatric hospitals, where the population to be transitioned is primarily adults with intellectual or developmental disabilities.

Day-to-day transition work is performed by transition coordinators. These coordinators are employed in several different organizational settings:

1. DCH and DBHDD employees who specialize in MFP transitions
2. Contracted transition agencies retained by the state to perform transition coordination on a fee basis
3. Aging and Disability Resource Connection regional offices, which are operated by Area Agencies on Aging in 12 regions across the state
4. Independent Living Centers, including the disABILITY LINK in Decatur and other federally-funded centers across the state
5. Provider agencies that hold contracts to deliver waiver services and that perform pre-transition coordination as part of preparing to serve a new member

The transition coordinator is the case manager of the transition. Their job is to meet with the institutionalized person, conduct a comprehensive assessment of community needs, identify a qualified community residence, secure a 1915(c) waiver placement, build the provider team that will deliver services after discharge, arrange pre-discharge home modifications and supplemental services, coordinate the day of discharge, and stay engaged with the person for the full 12-month demonstration period.

The waiver coordination piece is critical, and it is where most of the operational complexity of an MFP transition sits. Money Follows the Person is not itself a benefit package. It is an enhanced-match overlay on top of one of Georgia's existing 1915(c) home and community-based services waivers. Every MFP participant must be enrolled in a waiver concurrently, and the choice of waiver depends on the person's age, disability profile, and clinical needs.

The Five Georgia Waivers Used With MFP

Georgia operates five primary 1915(c) waivers that serve as the underlying service-delivery vehicle for Money Follows the Person transitions. Each waiver targets a different population, has its own service array, and has its own waiting list and capacity constraints. Understanding which waiver fits a given transition is the first analytical step in MFP planning.

CCSP, the Community Care Services Program, serves elderly individuals (age 65 and older) and adults age 18 to 64 with physical disabilities who require a nursing facility level of care. CCSP covers personal care services, adult day health, alternative living services in personal care homes, home-delivered meals, emergency response systems, home modifications, respite care, and skilled nursing visits. CCSP is administered through Area Agencies on Aging in Georgia's 12 aging service regions.

SOURCE, the Service Options Using Resources in a Community Environment program, serves the same target population as CCSP (elderly and adults with physical disabilities meeting a nursing facility level of care) but layers an enhanced primary care medical home on top of the standard waiver service array. SOURCE participants are enrolled with a SOURCE primary care provider who coordinates all medical care, attends case conferences, and is responsible for keeping the person stable in the community. SOURCE is administered through DCH-contracted SOURCE provider organizations.

ICWP, the Independent Care Waiver Program, serves adults age 21 to 64 with traumatic brain injury, spinal cord injury, or other physical disabilities producing complex medical needs. ICWP supports a higher level of personal care than CCSP or SOURCE, including the option for 24-hour personal care for individuals who require that intensity, cognitive rehabilitation services, augmentative communication devices, and assistive technology. ICWP is operated by DCH.

NOW, the New Options Waiver, serves individuals with intellectual or developmental disabilities who do not require the intensive supports of the COMP waiver. NOW emphasizes self-direction, supported employment, and community integration. Participants typically live in their own home or a family home with daily but not round-the-clock support. NOW is operated by DBHDD.

COMP, the Comprehensive Supports Waiver Program, serves individuals with intellectual or developmental disabilities who require more intensive supports, typically including 24-hour residential staffing, positive behavioral supports, intensive day programs, and complex health support. COMP participants frequently live in small group residences with two to three other individuals (still under the MFP fewer-than-4-unrelated-residents standard) with around-the-clock staffing. COMP is also operated by DBHDD.

The waiver selection for an MFP transition is made based on the person's disability profile, level-of-care determination, available family supports, housing options, and individual choice. For a 78-year-old transitioning out of a nursing facility back to a family member's home with daily personal care needs, CCSP or SOURCE is the typical fit. For a 28-year-old with a traumatic brain injury transitioning out of a long-term acute care hospital, ICWP is the right fit. For an adult with intellectual disability transitioning out of an ICF/IID into a small group residence with round-the-clock support, COMP is the typical fit.

Qualifying Institutional Residence and the 90-Day Rule

To be eligible for MFP, a person must have lived in a qualifying institution for at least the federally required minimum consecutive stay. The qualifying institutions are:

• Medicaid-certified nursing facilities. These are the long-term care facilities licensed by the Department of Community Health and certified for Medicaid payment under 42 CFR Part 483.
• Intermediate Care Facilities for Individuals with Intellectual Disabilities. These are residential facilities serving people with intellectual disability who require active treatment and 24-hour supervision. Georgia operates several state-owned ICF/IIDs and contracts with private ICF/IIDs as well.
• Long-term inpatient hospitals. These include long-term acute care hospitals, inpatient rehabilitation facilities, and state psychiatric hospitals, where a person has had a continuous inpatient stay of at least 90 days.

The ACA Section 2403 standard has been in effect since 2010. Prior to ACA Section 2403, the qualifying stay was longer, which dramatically narrowed the pool of eligible people. The 2010 reduction was one of the most consequential changes to MFP because it opened transition planning to people who had recently been admitted to a nursing facility (typically after a hospital stay for a stroke, hip fracture, cardiac event, or major surgery) and who, with appropriate community supports, could realistically return home rather than settling into long-term institutional placement.

The qualifying stay must be consecutive. Brief leaves of absence (for instance, a 48-hour hospital stay for a medical issue) generally do not reset the count, but a discharge to the community followed by readmission does. Medicaid must have paid for at least one day of the qualifying stay. The person can have entered the facility under private pay or Medicare and converted to Medicaid during the stay, and the Medicaid coverage of even a single day is sufficient to satisfy the federal requirement.

Qualified Community Residence Rules

The other side of the institutional-stay test is the residence the person is transitioning into. To qualify for MFP, the destination must be a "qualified community residence." The federal regulation defines this as:

• The person's own home (a residence the person owns or leases in their own name)
• A family home (a home owned or leased by a relative, where the person is welcome to live)
• A home shared by the person with a small number of unrelated individuals, within the federal household size limit
• A small group residence specifically designed and licensed to meet the federal residence definition

The federal cap on unrelated residents is one of the most frequently misunderstood pieces of MFP eligibility. A large assisted living facility is not a qualified MFP residence even if it is licensed and even if it provides exactly the services the person needs, because it exceeds the federal limit on unrelated residents. A small group home that meets the federal household limit is a qualified residence. A traditional large personal care home is not a qualified residence.

The federal standard is designed to ensure that MFP transitions actually move people into integrated community settings, not simply from one congregate care facility to a slightly smaller congregate care facility. The integration mandate from Olmstead is the policy driver, and the residence rules are how MFP operationalizes that mandate at the housing level.

Relatives count as relatives broadly. A son's home, a daughter's home, a sibling's home, a grandchild's home, a niece or nephew's home, and the home of any other relative all count as a "family home" regardless of household size. A small apartment shared with unrelated roommates may be a qualified residence if the household meets the federal size limit. The participant's own home, owned outright or rented in the participant's own name, is always a qualified residence regardless of household composition.

The 12-Month Demonstration Period and What It Pays For

The MFP demonstration period is exactly 365 days from the day of community discharge. During those 12 months, the federal government pays Georgia an enhanced share of the cost of every covered service the participant receives, above the regular federal match rate. This enhanced match premium is the program's principal financial incentive for the state to invest in transitions.

The services covered during the demonstration period fall into three categories:

First, all standard 1915(c) waiver services. Whatever the participant's waiver normally covers (personal care, adult day health, home modifications, skilled nursing, day programs, behavioral supports, transportation, respite, supported employment) is fully covered during the 12 months and is reimbursed at the enhanced federal matching rate.

Second, all standard Medicaid State Plan services. The participant remains on Medicaid as their primary payer for primary care, specialty care, prescription drugs, inpatient hospitalization, durable medical equipment, mental health services, and every other State Plan benefit. These services are also reimbursed at the enhanced federal matching rate during the demonstration period.

Third, MFP supplemental services. These are one-time pre-discharge and immediate-post-discharge services that are not normally part of the State Plan or the waiver service array. They include:

• Security deposits and first month of rent
• Utility activation deposits
• Basic household furniture (bed, dresser, kitchen table, living room seating)
• Kitchen supplies, dishware, and small appliances
• Pre-discharge home modifications (ramps, grab bars, accessible bathroom fixtures, widened doorways)
• Personal emergency response system installation and the first months of service
• Initial groceries and household supplies
• Transportation home on the day of discharge
• Pre-discharge medication bridge supply
• Move-in support services

The MFP supplemental services budget is capped per individual, with flexibility for documented additional need (for instance, a more expensive home modification required to make a bathroom truly accessible for a person with significant mobility limitations).

After the 365 days of the demonstration period end, the participant continues on the same 1915(c) waiver they were enrolled in during MFP. The waiver continues indefinitely as long as the participant remains eligible. The only changes at month 13 are that the federal match returns to the regular rate and the transition coordinator's intensive engagement reduces (although ADRC, AAA, and waiver case management continue at their normal cadence). The services themselves continue uninterrupted.

Pre-Transition Planning and the Transition Coordinator's Job

The transition coordinator's role in the months before discharge is extensive. A well-run MFP transition typically takes 3 to 6 months of pre-discharge planning, sometimes longer if the housing situation is complex or if waiver capacity is constrained. The major workstreams are:

Comprehensive assessment. The transition coordinator visits the person at the institution, often multiple times, and assesses needs across every domain of community living: medical, behavioral health, personal care, mobility, communication, transportation, housing, food security, social support, financial resources, and legal status. The assessment forms the foundation for the person-centered transition plan.

Waiver placement. The transition coordinator works with the DCH or DBHDD waiver office to secure a slot on the appropriate waiver. For CCSP and SOURCE, slots are generally available but require enrollment paperwork and a Level of Care determination. For ICWP, slots are scarcer and may require waiting list time. For NOW and COMP, the waiver waiting list in Georgia is long and an MFP transition typically receives priority placement.

Housing identification. The transition coordinator helps the person identify a qualified community residence. This may be their pre-institution home (if they retained ownership), a family member's home (if a family member is willing and the household supports the person's needs), or a new rental. For new rentals, the coordinator helps with the housing search, security deposit through MFP supplemental services, and lease negotiation.

Provider team assembly. The coordinator identifies the personal care agency, adult day health program, skilled nursing provider, transportation provider, behavioral health provider, and any specialty providers the person will need. Each provider must be enrolled with the appropriate Medicaid program and credentialed to serve the participant.

Home modifications. Pre-discharge home modifications are completed before the day of discharge so the home is ready when the person arrives. Common modifications include ramps for wheelchair access, grab bars in bathrooms and hallways, accessible bathroom fixtures (roll-in showers, raised toilets, accessible vanities), widened doorways, and bedroom modifications.

Discharge planning conference. In the days before discharge, the transition coordinator convenes a discharge planning conference at the institution that includes the institution's social worker and discharge nurse, the participant, family members, the receiving primary care provider, the personal care agency, and other community providers. The conference reviews the discharge plan, the medication list, the transportation arrangements, and the first-week service schedule.

Day-of-discharge transportation. The transition coordinator arranges transportation from the institution to the new home and is typically present on the day of discharge to meet the participant at the home, walk through the home, confirm that the personal care agency has arrived, and conduct an initial safety and orientation check.

GA Deinstitutionalization History and the Population Still in Institutions

To understand Money Follows the Person in Georgia, it helps to know where the state has come from on deinstitutionalization. Georgia has, over the past 30 years, closed several large state institutions for people with developmental disabilities and substantially reduced its institutional census.

Brook Run, a state institution in DeKalb County that at its peak served more than 1,000 individuals with developmental disabilities, was closed after several decades of advocacy and litigation. The closure was one of the early large-scale deinstitutionalizations in the Southeast.

Gracewood State School and Hospital in Augusta, originally opened in 1921 and at one point one of the largest institutions for people with intellectual disability in the Southeast, was closed following the settlement of the federal civil rights lawsuit United States v. Georgia. The lawsuit, filed by the U.S. Department of Justice under the Olmstead integration mandate, required Georgia to transition individuals from state psychiatric hospitals and DD institutions into community settings on an accelerated timeline.

Southwestern State Hospital in Thomasville also closed as part of the broader Olmstead-driven deinstitutionalization push. The remaining state psychiatric hospitals (Georgia Regional Hospital Atlanta, East Central Regional Hospital in Augusta, Central State Hospital in Milledgeville which itself substantially downsized, West Central Regional Hospital in Columbus, and Northwest Georgia Regional Hospital in Rome) have all reduced their long-stay census significantly.

Despite this progress, Georgia continues to have a sizable institutional long-term care population. A substantial number of Georgians live in Medicaid-certified nursing facilities at any given time. Several hundred to a few thousand live in ICF/IIDs. Several hundred more are long-stay patients in state psychiatric hospitals. Each of these populations is the source pool for Money Follows the Person transitions, and the state's MFP program continues to identify, assess, and transition individuals year after year.

Things Commonly Missed in Georgia MFP Planning

1. The institutional stay requirement was reduced by the Affordable Care Act of 2010. Some older guidance still references the original longer requirement, which is no longer the standard. Anyone who has been in a qualifying institution for the required minimum stay with Medicaid paying for at least one day is potentially MFP-eligible.

2. The MFP transition is voluntary. The person (or their legal representative if they have one) must affirmatively choose to transition. No one can be required to leave an institution. Conversely, an institution cannot refuse to participate in a transition that the resident has chosen.

3. Probation, parole, and other community supervision do not affect MFP eligibility. A person on community supervision who is otherwise Medicaid-eligible can transition through MFP just like anyone else.

4. MFP supplemental services pay for one-time pre-transition costs that traditional Medicaid does not cover. Security deposits, furniture, pre-discharge home modifications, and initial groceries are MFP-fundable. Ongoing rent and ongoing utilities are not (those are paid from the participant's own income, Social Security, or other personal resources).

5. The enhanced federal match applies only during the 365-day demonstration period. After month 13, federal match returns to the regular rate. Services continue at the same level; only the financing mechanism changes.

6. A 1915(c) waiver enrollment is mandatory and runs concurrently with MFP. MFP is an overlay on top of a waiver, not a standalone benefit. Choosing the wrong waiver, or failing to secure a waiver slot in time, can derail the entire transition.

7. The federal qualified community residence standard excludes most assisted living facilities. A person who wants to transition into a large assisted living facility is not MFP-eligible for that transition. Alternative options (family home, small group home meeting the federal standard, own apartment) must be explored.

8. Relatives count broadly. Sons, daughters, siblings, grandchildren, nieces, nephews, in-laws, and other relatives are all "family" for purposes of qualified community residence rules.

9. Transitions out of long-term inpatient hospitals (not just nursing facilities and ICF/IIDs) are MFP-eligible if the inpatient stay meets the federally required minimum duration. This includes long-term acute care hospitals after a major medical event, inpatient rehabilitation after a stroke or traumatic brain injury, and long-stay psychiatric hospitalization.

10. Pre-discharge home modifications can begin before discharge and are completed before the participant arrives at the new home. Waiting until after discharge to start ramp construction or bathroom modifications is a common planning error that creates dangerous gaps.

11. Olmstead originated in Georgia, and the case law continues to evolve. The Georgia Advocacy Office and Atlanta Legal Aid Society both continue to monitor and litigate Olmstead enforcement issues, including unnecessary institutionalization complaints.

12. DBHDD is the lead for transitions involving intellectual or developmental disability, and the NOW and COMP waiver waiting lists are managed by DBHDD. DCH leads for elderly and physical disability transitions through CCSP, SOURCE, and ICWP.

13. Georgia's MFP program has been continuously operational since 2007 and has helped thousands of individuals transition to community settings.

14. The Consolidated Appropriations Act, 2023 (Public Law 117-328) at Section 5114 reauthorized MFP at $450 million per year through fiscal year 2027 (funding through September 30, 2027) and also extended the related home and community-based services spousal-impoverishment protections through that same date.

15. Medicaid level-of-care determinations are required for waiver enrollment. For CCSP, SOURCE, and ICWP, the determination is a nursing facility level of care. For NOW and COMP, the determination is an ICF/IID level of care. Without an approved Level of Care, the waiver enrollment cannot proceed and the MFP transition stalls.

Worked Examples

Annie, 78, Atlanta: Nursing facility transition to son's home with CCSP

Annie has been a resident of Manorhouse Atlanta, a Medicaid-certified nursing facility, for 5 years. She was admitted after a stroke that left her with right-side hemiparesis and mild expressive aphasia. Her son David, 52, lives in a single-family home in Decatur with his wife and grown children. David has been visiting Annie weekly and has indicated to the facility social worker that he and his wife are interested in bringing Annie home if community supports can be arranged.

The Manorhouse social worker connects David with the local ADRC office. An ADRC transition coordinator visits Annie at the facility and conducts a comprehensive assessment. Annie is alert, oriented, and able to clearly express her preference to live with David. She is incontinent, requires assistance with all activities of daily living, takes 8 daily medications, and has a history of falls. Her son's home has stairs at the front entrance, no first-floor bathroom (the home was built in 1955), and no first-floor bedroom.

The transition coordinator builds a transition plan with David. The CCSP waiver is the appropriate fit: Annie meets nursing facility level of care, her son's home is a qualified community residence (family home), and CCSP covers the personal care and skilled nursing services she will need. Pre-discharge home modifications funded through MFP supplemental services include a ramp at the front entrance, conversion of a first-floor den into a bedroom, and conversion of a first-floor half-bath into a full accessible bathroom with a roll-in shower and grab bars. Total modification cost is approximately $14,000, funded through a combination of MFP supplemental services and CCSP environmental modification benefits.

Annie's CCSP service plan includes personal care services 6 hours per day from a contracted agency, adult day health 3 days per week at a nearby center, skilled nursing visits twice per week, medication management, and Lifeline emergency response. Her primary care provider is reassigned from the Manorhouse medical director to a community-based primary care practice in Decatur that participates in Medicaid.

The discharge date is set for a Tuesday. The transition coordinator is present at Manorhouse for the discharge conference Monday afternoon and at David's home Tuesday morning when Annie arrives by wheelchair-accessible transport. The personal care aide arrives at 9 a.m. and stays through 3 p.m. The skilled nursing visit is Tuesday afternoon. David and his wife are home throughout the first week to support the transition.

During the 12-month demonstration period, Annie's services are reimbursed at the enhanced federal match rate. Quarterly Quality of Life assessments confirm that Annie is doing well in the community: she has gained weight, her mood has improved, her medication regimen has been streamlined from 8 medications to 6, and she has had no falls. At month 13, the financing transitions to regular CCSP at the standard federal match rate. Annie continues on CCSP indefinitely.

Marcus, 35, Albany: ICF/IID transition to family home with NOW

Marcus has intellectual disability and was placed at an ICF/IID at age 23 after his parents felt they could no longer manage his care at home. He has been at the ICF/IID for 12 years. His parents are now in their late 60s. His older sister Tamika, 41, lives in Albany in a 4-bedroom home with her husband and two children and has been increasingly involved in Marcus's care over the past several years. After multiple discussions with Marcus, who clearly expresses his preference to live with Tamika's family, Tamika contacts the DBHDD regional office about an MFP transition.

A DBHDD transition coordinator is assigned. The coordinator assesses Marcus's needs: he is verbal but uses augmentative communication for complex needs, requires support with all activities of daily living, has a seizure disorder controlled with medication, attended day programs at the ICF/IID, and would benefit from continued day programming and supported community engagement in Albany. The NOW waiver is the appropriate fit: Marcus has ICF/IID level of care, can be served with daily but not 24-hour residential staffing, and would benefit from the supported employment and community integration emphasis of NOW.

Pre-discharge planning takes 4 months. The transition coordinator works with Tamika to identify a community-based day program in Albany that serves adults with intellectual disability, arranges for an augmentative communication device evaluation and procurement, contracts with a community support worker agency for daily support hours, and coordinates with a community neurologist for ongoing seizure management. MFP supplemental services pay for bedroom furniture for Marcus's room in Tamika's home, an iPad-based AAC device, and initial household supplies.

Marcus moves to Tamika's home in Albany. His NOW service plan includes community support workers 6 hours per day Monday through Friday, a community-based day program 3 days per week, a community-based recreational program 2 evenings per week, and family-directed respite for Tamika. Marcus's seizures remain well-controlled. He becomes increasingly verbal in his new home, makes friends at the day program, and participates in family events that he had not been part of during his ICF/IID years.

Diane, 62, Macon: Wants to transition to a 24-unit assisted living facility (not MFP-eligible)

Diane has been at a nursing facility in Macon for 14 months after a major medical event. She is medically stable, ambulatory with a walker, and capable of independent living with some support. She has been researching assisted living facilities and wants to move to a 24-unit ALF in Macon that has private apartments, congregate meals, and personal care available on-site.

A CCSP case manager evaluates Diane's situation. The 24-unit ALF is not a qualified MFP community residence because it exceeds the federal cap on unrelated residents in a qualified community residence. Diane is informed that an MFP transition is not available for this destination. Several alternatives are discussed:

Option A: Transition to her sister Patricia's home in Macon with CCSP services. Patricia has a finished basement apartment that could serve as Diane's living space. This would be MFP-eligible (family home) and Diane would receive CCSP personal care, adult day health, and skilled nursing visits.

Option B: Transition to her own apartment (a 1-bedroom rental) with CCSP services. This would be MFP-eligible (own home) and would provide the most independence.

Option C: Move to the 24-unit ALF as a private-pay or non-MFP transition. CCSP services would continue at the ALF if the ALF is a CCSP-participating alternative living service provider, but the MFP supplemental services and the enhanced federal match would not apply.

Diane chooses Option B. The transition coordinator helps her find a 1-bedroom apartment near her sister Patricia, MFP supplemental services pay for the security deposit, first month of rent, and basic furniture. Diane receives CCSP personal care 4 hours per day and weekly skilled nursing visits.

Jamal, 28, Savannah: TBI inpatient rehab transition to sister's home with ICWP

Jamal sustained a severe traumatic brain injury in a motor vehicle accident 4 months ago. After acute hospitalization at Memorial Health University Medical Center in Savannah, he was transferred to a long-term acute care and inpatient rehabilitation facility in Savannah for ongoing rehabilitation. He has completed 90+ days of inpatient stay (now well past the 90-day MFP qualifying threshold) and his rehabilitation team has determined that he is ready for community discharge with intensive supports.

Jamal's sister Marcia, 34, lives in a 3-bedroom home in Savannah and has indicated that she wants Jamal to come live with her. Jamal is alert, communicates through short phrases and gestures, requires assistance with all activities of daily living, has cognitive deficits affecting executive function and short-term memory, and needs ongoing physical therapy, occupational therapy, and speech-language pathology.

The ICWP waiver is the appropriate fit. An ICWP transition coordinator is assigned. The ICWP service plan includes personal care services 24 hours per day initially (8-hour shifts from contracted providers), cognitive rehabilitation 3 times per week, outpatient physical therapy and occupational therapy twice per week each, speech-language pathology twice per week, and assistive technology evaluation for an augmentative communication device. Marcia's home requires modifications: a ramp at the front entrance, a hospital bed and accessible bathroom equipment in Jamal's room, and home safety improvements (door alarms, secure medication storage). MFP supplemental services pay for the modifications and the initial assistive technology evaluation.

Jamal moves to Marcia's home. The 24-hour personal care intensity reduces over the first 6 months as Jamal's independence improves. By month 12, he is at 16 hours of personal care per day and has gained substantial functional independence. His cognitive rehabilitation continues at a community-based clinic.

Yolanda, 42, Athens: State psychiatric hospital transition to 3-bedroom group home with COMP

Yolanda has intellectual disability and a co-occurring behavioral health condition. She has been a resident of Georgia Regional Hospital Atlanta for 8 years following a series of community placement failures earlier in her adult life. Her treatment team at Georgia Regional has concluded that she is appropriate for community placement with intensive supports.

A DBHDD transition coordinator works with the Georgia Regional team and identifies a 3-bedroom group home in Athens, operated by a provider agency that contracts with DBHDD for COMP residential services. The group home will house Yolanda and 2 other adults with intellectual disability, all of whom will receive 24-hour staffing, day programs, behavioral support services, and clinical oversight from the provider's behavior specialist team. The small household of 3 residents meets the federal qualified community residence standard.

Pre-discharge planning includes a positive behavior support plan, an individualized service plan, day program enrollment at a community-based program in Athens, a community psychiatrist for ongoing medication management, and basic furnishings for Yolanda's bedroom in the group home funded through MFP supplemental services. The discharge is planned over an extended timeline with multiple pre-discharge home visits and overnight stays at the group home to support Yolanda's adjustment.

Yolanda transitions to the group home. Her COMP service plan includes 24-hour staffing, day program 5 days per week, weekly behavior support consultation, monthly psychiatric follow-up, recreation and community integration activities, and family visits with her parents who live in Lawrenceville. The transition coordinator stays engaged throughout the 12-month demonstration period and Yolanda's behavior support outcomes are monitored quarterly.

Robert, 71, Columbus: Nursing facility transition to own home with SOURCE

Robert is a retired Army veteran who has been a resident of a nursing facility in Columbus for 18 months after a fall that resulted in a hip fracture, surgical repair, and complications during rehabilitation. He owns a single-family home in Columbus outright (paid off years ago), has retained the home throughout his nursing facility stay (with his nephew checking on it and doing basic maintenance), and is determined to return there.

A SOURCE primary care medical home in Columbus expresses interest in serving Robert as their MFP transition participant. The SOURCE model fits Robert well: he has multiple chronic conditions (Type 2 diabetes, hypertension, mild congestive heart failure, history of falls) that benefit from an integrated primary care medical home approach, and he is medically complex enough to need close ongoing primary care coordination.

The transition coordinator works with Robert and his nephew to prepare the home. Pre-discharge home modifications include grab bars in both bathrooms, a raised toilet, a shower bench, removal of throw rugs that present fall risk, improved lighting in hallways, and a stair lift to the second floor (where Robert prefers to sleep in his original bedroom). MFP supplemental services pay for the modifications and for an initial supply of groceries and household supplies. The Aging and Disability Resource Connection of the Lower Chattahoochee region serves as the local coordination point.

Robert returns home. His SOURCE plan includes skilled home health services 5 days per week initially (transitioning to 3 days per week by month 6), personal care 6 hours per day, weekly visits from the SOURCE primary care provider's care coordinator, monthly visits from the primary care provider, durable medical equipment (a walker, a wheelchair for longer distances, and a personal emergency response system), and home-delivered meals 5 days per week. The nephew remains involved as Robert's informal family caregiver and primary support contact.

Putting It Together

Money Follows the Person is the federal Medicaid demonstration program that funds the work of Olmstead implementation in Georgia. The program traces directly to the 1999 Supreme Court decision that originated at Georgia Regional Hospital Atlanta, the same state psychiatric facility that, decades after Olmstead, continues to be a source of MFP transitions for adults with intellectual disability who are ready to return to community settings.

For families and providers thinking about whether MFP is the right pathway for someone they care about, the practical screening questions are: Has the person been in a Medicaid-certified nursing facility, ICF/IID, or long-term inpatient hospital for the federally required minimum stay with Medicaid paying for at least one day? Does the person want to leave the institution and return to community living? Is there a qualified community residence available (own home, family home, or small group home meeting the federal standard)? Will the person need at least one HCBS waiver service after the transition (almost always yes for people coming out of long-term institutional placement)? If the answers are yes, MFP is likely available, and a call to the DCH MFP program, the local ADRC, or the DBHDD regional office is the next step.

Brevy, the eldercare company that publishes this guide, tracks Money Follows the Person utilization in Georgia and across the country and works with families to identify whether an MFP transition is the right path for their loved one. The next step is usually a conversation with the institution's social worker or discharge planner, followed by a referral to the appropriate transition coordinator.

Georgia MFP transition contacts

Money Follows the Person transition planning typically takes 3 to 6 months from initial contact to community discharge. Beginning the process early gives the transition coordinator time to assemble the right team, identify the right housing, complete pre-discharge modifications, and prepare the participant and family for a successful return to community living. Use the contacts below to begin a transition inquiry, to ask about specific waivers, to escalate Olmstead enforcement concerns, or to connect with legal advocacy resources.

Learn More

• Georgia Medicaid Overview
• Georgia Medicaid Long-Term Care
• Georgia HCBS Waivers
• Georgia CCSP Waiver
• Georgia SOURCE Waiver
• Georgia ICWP Waiver

Find personalized help planning a Money Follows the Person transition at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.