Money Follows the Person

Individuals who wish to transition back to the community under the MFP demonstration will be discharged with a list of services that will help them live a healthy, fulfilling, and well-balanced life in their chosen community. 

Transitioning looks at the individual from a person-centered lens, creating a system that builds capacity for receiving improved healthcare at home with paid caregiving services.

Transition Plan

Food Plan

Home and Community-Based Services give target population individuals the opportunity to receive services in their own home or community instead of in the hospital or institution where they are often isolated.

HCBS services offered under Medicaid, provide services that are meant specifically for certain populations. For example, MFP HCBS will help with services for the aging - 65 years and over, as well as individuals with physical disabilities. Services provided could be Personal Care Services, Home Care, or Case Management services.

Individuals who are eligible to transition and make their own choice to return to the community can decide if they want to move back to their family home or a rental home. CMS stipulates two types of qualified residences available for them to select from for short-term housing assistance of six months:

1. A home owned or leased by the individual or individual’s family member;

2. An apartment with an individual lease, with lockable access and egress which includes sleeping, bathing, and cooking areas over which the individual or the individual’s family has domain and control

A Transition Coordinator will work with the eligible participant when they decide they would like to transition out of LBJ Medical Center or a CMS-qualified residence.

Housing Plan

Eligible and qualified individuals for MFP may require short-term services. These short-term services after being approved by CMS for qualified individuals, will be covered by MFP, which includes:

• Rental deposit and fees

• Utility expenses for up to six months

• Food security for up to one month

• Home accessibility modifications (as required for participant only and approved by an Occupational Therapist)

• Vehicle modifications

• Assistive technology

• Durable Medical equipment (if prescribed by LBJ physician upon discharge from the facility).

There are existing service providers - qualified by AS Medicaid and are therefore paid through Medicaid. These include: 

• LBJ Medical Center

• Department of Health Clinics

• Hope House

• My Vision Eye Care

• Medquest

• Samoa Prosthetics

• Med Assist (New Zealand) 

• Adventists Health Castle USA (Maryland and Washington DC). 

As MFP builds capacity for more HCBS in the community, interested service providers must be licensed by the Department of Health Licensure Board, have a current Business License, and be qualified by AS Medicaid. Please see https://medicaid.as.gov/downloads/Provider-Agreement/ASMSA_PA_Checklist.pdf  for further information on other requirements