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What is CFSS

  

Empowering Choice. Building Independence. Supporting Your Life at Home and in the Community.

CFSS Overview

Community First Services and Supports (CFSS) is Minnesota’s innovative, self-directed home and community-based service that began rolling out on October 1, 2024. It replaces Personal Care Assistance (PCA) and the Consumer Support Grant (CSG), providing more flexibility, control, and independence for people who need support to live safely in their homes and participate fully in their communities.

With CFSS, you can:

  • Choose who provides your care – even a spouse or minor child (with certain limitations)CFSS-Guidance-5.29.2025.
  • Hire people you trust and direct their work.
  • Purchase approved goods, services, and personal emergency response systems (PERS) that meet your needs.
  • Decide between two service models: the Agency Model or the Budget      Model.
  • Use a Worker Training and Development Budget to ensure your staff meet your  specific care needsCFSS_guidelines.


Support Groups

  

Who is Eligible?

Eligibility for CFSS is the same as PCA:

  • You must have an assessed need for help with Activities of Daily Living      (ADLs) like bathing, dressing, eating, mobility, or toileting.
  • You must complete a MnCHOICES assessment with your lead agency or care coordinator Community First Service….
  • You may qualify whether you are on Medical Assistance, Medicare, or other      applicable insurance programs.

Benefits of CFSS

CFSS offers choice, flexibility, and control:

  • Hire family members or trusted friends (including spouses or parents of minors, within program limits).
  • Purchase goods/services that increase your independence or reduce your need for human assistance.
  • Skill-building – develop abilities to direct your own care and manage your supports.
  • Two service models to fit your comfort level in managing care.

Two Service Models Explained

1. Agency Model

  • The provider agency is the employer of your workers.
  • The agency recruits, hires, trains, supervises, schedules, and pays staff.
  • You still direct your daily services and have a say in who works with you CFSS-Guidance-5.29.2025.
  • If you purchase goods or services, an FMS provider helps coordinate      those purchases.

2. Budget Model

  • You are the employer of your workers.
  • You hire, train, schedule, supervise, and pay staff (with help from a Financial Management Services (FMS) provider).
  • You decide on wages (within DHS guidelines) and purchase goods, services, and PERS as outlined in your approved plan.
  • Required if you are only purchasing goods, services, or PERS without personal care services Community First Service….

How CFSS Supports Independence

CFSS funds can be used for:

  • Personal Care Services – help with ADLs like bathing, dressing, transfers, and eating.
  • Goods and Services – adaptive equipment, technology, or items that increase safety and independence.
  • Environmental Modifications – changes in your home that make daily life easier and safer.
  • Personal Emergency Response Systems (PERS) – devices to call for help quickly in emergenciesCFSS_guidelines.

CFSS Participant Rights

Every person using CFSS has rights that protect dignity, independence, and choice. These include:

  • Being treated with respect.
  • Making informed decisions about your care.
  • Privacy and confidentiality.
  • Freedom from abuse, neglect, and exploitation.

📄 Read the full list here: Your Rights as a CFSS Participant (links to your detailed “Person’s Rights” page).


1. Our Services – How SmartCare Link LLC Supports CFSS Participants

At SmartCare Link LLC, we are a DHS-enrolled Community First Consultation Services Provider dedicated to guiding clients and participants through every step of Minnesota’s Community First Services and Supports (CFSS) program.
We combine deep program expertise, person-centered planning, and responsive customer care to ensure participants make informed choices, receive quality services, and achieve greater independence.

Our work follows a proven consultation flow:
Educate → Plan → Guide → Assist → Approve → Support

01. Educate

With CFSS replacing PCA and CSG, many participants may not yet understand:

  • What CFSS is and how it works
  • How CFSS differs from PCA
  • Who is eligible
  • All services and supports available under CFSS

We provide clear, culturally competent education in multiple languages and formats.
This includes:

  • Explaining both Agency Model and Budget Model
  • Clarifying participant rights under Minn. Stat. §256B.85
  • Helping participants understand their role in self-direction
        Our goal is for every participant to be fully informed before making decisions.

02. Plan

Once participants understand CFSS, we:

  • Collaborate to create a personalized Consultant Services Support Plan that addresses needs, goals, and reasons for requesting CFSS.
  • Provide templates and forms to organize service requests and document needs.
  • Meet in-person at the participant’s home or preferred location to make planning comfortable.
  • Ensure the plan promotes independence, safety, and quality of      life.

We also:

  • Develop and maintain plans over time, adjusting as needs change
  • Allow unlimited plan revisions within CFSS scope
  • Redistribute updated plans to agencies, FMS providers, Care Coordinators, and Case Managers as applicable

03. Guide

We guide participants through:

  • Community involvement — regularly sharing information about local activities, resources, and supports
  • Understanding DHS rules and timelines for service delivery
  • Knowing their options when hiring workers or selecting FMS providers

Our neutrality policy ensures:

  • Participants are free to choose any enrolled FMS or CFSS agency provider
  • We never limit choice to certain providers
  • We offer a complete list of eligible providers

04. Assist

We assist participants with:

  • Plan revisions when needs or health conditions change
  • Recruiting, selecting, training, and supervising support workers
  • Setting wages and benefits within DHS guidelines
  • Implementing employment responsibilities under federal, state, and local tax, labor, and employment laws
  • Addressing and resolving service delivery issues promptly

We ensure worker competency by:

  • Verifying qualifications within 30 days of hire
  • Reassessing after condition changes or plan modifications
  • Documenting education, training, and experience
  • Conducting annual performance reviews based on direct observation

We also develop worker training and development plans so staff remain skilled and responsive to participant needs.

05. Approve

Our role in approving and overseeing service delivery includes:

  • Issuing Notices of Action when services/goods are denied, explaining      reasons (e.g., outside CFSS scope, unrelated to assessed need, no increase in independence)
  • Coordinating with Care Coordinators or Case Managers when denying or reducing services
  • Ensuring goals and objectives are updated with every plan revision
  • Maintaining full documentation that the participant’s choice of service model and providers was offered and respected

06. Support

We provide ongoing, 24/7 participant support:

  • Toll-free phone, fax, and TTY for deaf/hard-of-hearing clients
  • Translation and interpreter services, including American Sign Language
  • Alternate-format materials for accessibility
  • Website-based communication for online consultation requests
  • One-business-day response time to participant requests

We also:

  • Conduct annual satisfaction surveys and implement quality improvement plans
  • Track and respond to complaints in a timely, documented manner
  • Maintain culturally competent practices for participants of all backgrounds, ages, disabilities, and chronic conditions

Benefits of Working with SmartCare Link LLC

  • Expertise – Years of knowledge in CFSS program rules and person-centered planning
  • Clarity  – Simplified explanation of complex DHS policies and options
  • Flexibility  – Unlimited plan revisions and adaptable service approaches
  • Quality   – Highly trained, diverse, and respectful consultants
  • Access – Multilingual support, multiple contact options, and in-home      consultations
  • Compliance - Every action aligned with DHS, CFSS policies, and employment laws

2. Resources & Tools

Empowering participants, providers, and care coordinators with quick access to trusted DHS-approved materials, tools, and templates.

Purpose

Our Resources & Tools hub ensures that every participant, care coordinator, and partner agency can easily find verified, up-to-date CFSS guidance. Every link and document here is either directly sourced from the Minnesota Department of Human Services (DHS) or adapted with DHS policy in mind — ensuring full compliance and accuracy.

We’ve organized these resources into three easy-to-navigate categories: Participant Resources, Provider & Care Coordinator Tools, and Compliance & Policy Links.

Participant Resources

Guides and rights information to help participants make informed decisions and succeed in CFSS.

  1. CFSS Consultation Services Provider Requirements
    • Understand the role of a consultation provider: education, plan development, and neutral model guidance.
    • DHS Official List of Enrolled CFSS Consultation Providers
      Suggested Image: Smiling participant and consultant reviewing a support plan at a kitchen table.

  1. DHS Goods & Services Guidelines
    • Learn what goods and services can be purchased under CFSS to improve independence or reduce reliance on human assistance.
    • Includes PERS (Personal Emergency Response Systems), adaptive equipment, and home modifications — all subject to DHS pre-approval.

  1. Rights & Responsibilities
    • Based on DHS policy and Minnesota statutes, this guide outlines your rights as a CFSS participant and the responsibilities that come with self-directed care.
    • Covers freedom of choice, safety protections, and grievance procedures.

Provider & Care Coordinator Tools

Templates and checklists that make CFSS service delivery seamless and compliant.

  1. CFSS Support Plan Templates
    • Download fillable DHS-6893P templates to create individualized service  delivery plans that meet DHS approval standards. 

  1. Service Delivery Plan Guides
    • Step-by-step DHS-aligned instructions for completing service delivery plans —  including examples for Agency Model and Budget Model participants.
      Suggested Image: Care coordinator and participant reviewing documents.

  1. Employer Responsibility Checklists (Budget Model)
    • Comprehensive checklists for participants acting as employers, covering recruiting, hiring, training, wage-setting, and compliance with SEIU agreements.

Compliance & Policy Links

Stay aligned with DHS regulations and ready for audits or reviews.

  1. CFSS Policy Manual
    • The primary source of truth for all CFSS requirements.
    • View CFSS Policy Manual
      Suggested Image: Official Minnesota DHS logo overlaying compliance documents.

  1. MnCHOICES Assessment Info
    • Learn how eligibility is determined and what to expect during your annual or reassessment visit.
    • Includes assessment timelines and required documentation.

  1. DHS CFSS FAQ
    • Quick answers to the most common CFSS questions — from transitioning from PCA to understanding your budget.
    • Visit DHS CFSS FAQ

Why This Matters

By keeping all participant guides, provider tools, and policy links in one place, SmartCare Link ensures:

  • DHS readiness for program reviews or audits.
  • Participant empowerment through education and transparency.
  • Provider efficiency with ready-to-use templates and checklists.
  • Care coordinator confidence with quick-reference, compliant materials.

Referral & Enrollment

Enroll now!

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