Community First Choice Texas: The Medicaid Entitlement With No Waitlist

The Program Most Families Don't Know Exists

Texas has some of the longest Medicaid waiver waitlists in the country. Families routinely wait 15 to 18 years for an HCS or TxHmL slot. During those years, many assume there is no community-based help available.

Community First Choice (CFC) changes that equation. Authorized under Section 1915(k) of the Social Security Act, CFC is a Medicaid entitlement — meaning there is no interest list, no waitlist, and no cap on the number of people served. If you qualify, services begin after the assessment is completed and a service plan is in place.

Who Qualifies for CFC

To be eligible for Community First Choice in Texas, an individual must meet two requirements:

Medicaid enrollment: The individual must be actively enrolled in Texas Medicaid. For adults with disabilities, this typically means having SSI eligibility (which automatically triggers Medicaid in Texas) or qualifying through the Medicaid for the Elderly and People with Disabilities (MEPD) pathway.

Institutional level of care: The individual must meet the functional criteria for an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) or a nursing facility level of care. This assessment evaluates whether the person needs substantial assistance with daily activities — bathing, dressing, eating, mobility, health maintenance — at a level that would otherwise require institutional placement.

There is no age requirement. CFC serves children and adults.

What CFC Covers

CFC provides supports that help the individual live in their own home or a family home rather than in an institution:

• Personal attendant services — assistance with bathing, dressing, grooming, eating, toileting, and mobility
• Habilitation services — training to acquire, retain, or improve skills in daily living, community participation, and self-care
• Emergency backup attendant services — coverage when the regular attendant is unavailable
• Voluntary training for the individual and their attendant — skill-building to increase independence

CFC does not cover the full range of services available under the HCS or CLASS waivers. It does not include day habilitation programs, residential placement, adaptive aids, or minor home modifications. Think of CFC as the core attendant care and habilitation layer — the foundation of community-based support that keeps someone out of an institution while they wait for more comprehensive waiver services.

Consumer Directed Services: Hiring Your Own Attendant

One of CFC's most practical features is the Consumer Directed Services (CDS) option. Under CDS, the individual (or their legally authorized representative) serves as the employer of record. They can recruit, hire, train, schedule, and manage their own attendant — including a family member.

This is a significant advantage for families where a parent or sibling is already providing care. The CDS option turns informal caregiving into a paid, structured arrangement, with the attendant's wages funded through the Medicaid budget allocated to the individual's service plan.

The Financial Management Services Agency (FMSA) handles payroll, tax withholding, and employer compliance. The family handles the day-to-day scheduling and supervision.

How to Apply

The entry point for CFC depends on the individual's disability type:

Intellectual or developmental disability: Contact your Local Intellectual and Developmental Disability Authority (LIDDA). The LIDDA conducts the Determination of Intellectual Disability (DID) and the functional assessment needed to verify the ICF/IID level of care.

Physical disability without IDD: Contact the individual's Medicaid managed care organization (MCO). The MCO coordinates the nursing facility level of care assessment.

The assessment process typically takes several weeks. Once the level of care is established and the service plan is approved, services can begin. There is no queue — the timeline depends on the speed of the assessment and provider availability.

CFC as a Bridge While Waiting for a Waiver Slot

For most Texas families, CFC is not the end goal. HCS, TxHmL, and CLASS waivers offer a much broader range of services — day programs, specialized therapies, residential supports, adaptive equipment. But those waivers have waitlists measured in years.

CFC fills the gap. A family can register on the HCS interest list through their LIDDA at age 14, start receiving CFC attendant services at age 18, and transition to full waiver services when their slot comes up years later. The two programs are not mutually exclusive — being on CFC does not affect your position on a waiver interest list.

For a walkthrough of how to coordinate CFC enrollment with the SSI age-18 redetermination, ABLE accounts, and waiver interest list management, the Texas SSI at 18 & Adult Disability Benefits Guide covers the full sequence from age 14 through 22.

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