Code of Colorado Regulations
2505 - Department of Health Care Policy and Financing
2505 - Medical Services Board (Volume 8; Medical Assistance, Children's Health Plan)
10 CCR 2505-10-8.500 - MEDICAL ASSISTANCE - SECTION 8.500 HCB-DD, CES, Oxygen, DME
Section 10 CCR 2505-10-8.503 - CHILDREN'S EXTENSIVE SUPPORT WAIVER PROGRAM (HCBS-CES)
Universal Citation: 2505 CO Code Regs 10 CCR 2505-10-8.503
Current through Register Vol. 47, No. 5, March 10, 2024
8.503 DEFINITIONS
A. ACTIVITIES OF DAILY LIVING (ADL) means
basic self-care activities including bathing, bowel and bladder control,
dressing, eating, independent ambulation, transferring, and needing supervision
to support behavior, medical needs and memory cognition.
B. ADVERSE ACTION means a denial, reduction,
termination or suspension from the HCBS-CES waiver or a HCBS waiver
service.
C. APPLICANT means as
defined in Section 8.390.1.
D.
AUTHORIZED REPRESENTATIVE means an individual designated by a Client, or by the
parent or guardian of the Client receiving services, if appropriate, to assist
the Client receiving service in acquiring or utilizing services and supports,
this does not include the duties associated with an Authorized Representative
for Consumer Directed Attendant Support Services (CDASS) as defined at Section
8.510.1.
E. CASE MANAGEMENT AGENCY
(CMA) means a public or private not-for-profit or for-profit agency that meets
all applicable state and federal requirements and is certified by the
Department to provide case management services for Home and Community Based
Services waivers pursuant to Section
25.5-10-209.5, C.R.S. and pursuant
to a provider participation agreement with the Department.
F. CLIENT means an individual who meets
long-term services and supports eligibility requirements and has been approved
for and agreed to receive Home and Community-based Services (HCBS).
G. CLIENT REPRESENTATIVE means a person who
is designated by the Client to act on the Client's behalf. A Client
representative may be:
(A) a legal
representative including, but not limited to a court-appointed guardian, a
parent of a minor child, or a spouse; or
(B) an individual, family member or friend
selected by the Client to speak for or act on the Client's behalf.
H. COMMUNITY CENTERED BOARD (CCB)
means a private corporation, for-profit or not-for-profit that is designated
pursuant to Section
25.5-10-209, C.R.S., responsible
for, but not limited to conducting Developmental Disability determinations,
waiting list management Level of Care Evaluations for Home and Community-based
Service waivers specific to individuals with intellectual and developmental
disabilities, and management of State Funded programs for individuals with
intellectual and developmental disabilities.
I. COST CONTAINMENT means limiting the cost
of providing care in the community to less than or equal to the cost of
providing care in an institutional setting based on the average aggregate
amount. The cost of providing care in the community shall include the cost of
providing Home and Community-based Services, and Medicaid State Plan benefits
including long-term home health services and targeted case
management.
J. COST EFFECTIVENESS
means the most economical and reliable means to meet an identified need of the
Client.
K. CONSUMER DIRECTED
ATTENDANT SUPPORT SERVICES (CDASS) means the service delivery option for
services that assist an individual in accomplishing activities of daily living
when included as a waiver benefit that may include health maintenance, personal
care and homemaker activities.
L.
DEPARTMENT means the Colorado Department of Health Care Policy and Financing,
the single state Medicaid agency.
M. DEVELOPMENTAL DELAY means as defined in
Section 8.600.4.
N. DEVELOPMENTAL
DISABILITY means as defined in Section 8.600.4.
O. EARLY AND PERIODIC SCREENING DIAGNOSIS AND
TREATMENT (EPSDT) means as defined in Section 8.280.1.
P. FAMILY means a relationship as it pertains
to the Client and is defined as:
A mother, father, brother, sister,
Extended blood relatives such as grandparent, aunt, uncle, cousin,
An adoptive parent,
One or more individuals to whom legal custody of a person with a developmental disability has been given by a court,
A spouse or,
The Client's child.
Q. FISCAL MANAGEMENT SERVICE (FMS) means the
entity contracted with the Department to complete employment related functions
for CDASS attendants and track and report on individual Client allocations for
CDASS.
R. GUARDIAN means an
individual at least twenty-one years of age, resident or non-resident, who has
qualified as a guardian of a minor or incapacitated person pursuant to
appointment by a parent or by the court. The term includes a limited,
emergency, and temporary substitute guardian but not a guardian ad litem
Section 15-14-102(4),
C.R.S.
S. GUARDIAN AD LITEM or GAL
means a person appointed by a court to act in the best interests of a child
involved in a proceeding under
Title 19,
C.R.S., or the "School Attendance Law of 1963," set forth in Article
33 of Title
22, C.R.S.
T. HOME AND COMMUNITY-BASED SERVICES (HCBS)
WAIVERS means services and supports authorized through a 1915 (c) waiver of the
Social Security Act and provided in community settings to a Client who requires
a level of institutional care that would otherwise be provided in a hospital,
nursing facility or Intermediate Care Facility for Individuals with
Intellectual Disabilities (ICF-IID).
U. INSTITUTION means a hospital, nursing
facility, or ICF-IID for which the Department makes Medicaid payments under the
state plan.
V. INTERMEDIATE CARE
FACILITY FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES (ICF-IID) means a
publicly or privately operated facility that provides health and habilitation
services to a Client with developmental disabilities or related
conditions.
W. LEGALLY RESPONSIBLE
PERSON means the parent of a minor child, or the Client's spouse
X. LEVEL OF CARE (LOC) means the specified
minimum amount of assistance a Client must require in order to receive services
in an institutional setting under the Medicaid State Plan.
Y. LEVEL OF CARE SCREEN means as defined in
Section 8.391.1.
Z. LICENSED
MEDICAL PROFESSIONAL means a person who has completed a 2-year or longer
program leading to an academic degree or certificate in a medically related
profession. This is limited to those who possess the following medical
licenses: physician, physician assistant and nurse governed by the Colorado
Medical License Act and the Colorado Nurse Practice Act.
AA. LONG-TERM SERVICES AND SUPPORTS (LTSS)
means the services and supports used by individuals of all ages with functional
limitations and chronic illnesses who need assistance to perform routine daily
activities.
BB. MEDICAID ELIGIBLE
means the Applicant or Client meets the criteria for Medicaid benefits based on
the Applicant's financial determination and disability determination when
applicable.
CC. MEDICAID STATE PLAN
means the federally approved document that specifies the eligibility groups
that a state serves through its Medicaid program, the benefits that the state
covers, and how the state addresses additional federal Medicaid statutory
requirements concerning the operation of its Medicaid program.
DD. MEDICATION ADMINISTRATION means assisting
a Client in the ingestion, application or inhalation of medication, including
prescription and non-prescription drugs, according to the directions of the
attending physician or other licensed health practitioner and making a written
record thereof.
EE. NATURAL
SUPPORTS means non paid informal relationships that provide assistance and
occur in the Client's everyday life such as, but not limited to, community
supports and relationships with family members, friends, co-workers, neighbors
and acquaintances.
FF. ORGANIZED
HEALTH CARE DELIVERY SYSTEM (OHCDS) means a public or privately managed service
organization that is designated as a Community Centered Board and contracts
with other qualified providers to furnish services authorized in Home and
Community Services for persons with Developmental Disabilities (HCBS-DD), HCBS-
Supported Living Services (HCBS-SLS) and HCBS- Children's Extensive Supports
(HBCS-CES) waivers.
GG.
PERSON-CENTERED SUPPORT PLAN (PCSP) means as defined in Section 8.390.1
DEFINITIONS.
HH. PRIOR
AUTHORIZATION means approval for an item or service that is obtained in advance
either from the Department, a state fiscal agent or the Case Management
Agency.
II. PROFESSIONAL MEDICAL
INFORMATION PAGE (PMIP) means as defined in Section 8.390.1
DEFINITIONS.
JJ. PROGRAM APPROVED
SERVICE AGENCY means a developmental disabilities service agency or typical
community service agency as defined in Section 8.600.4 et
seq., that has received program approval to provide HCBS-CES waiver
services.
KK. RELATIVE means a
person related to the Client by virtue of blood, marriage, adoption or common
law marriage.
LL. RETROSPECTIVE
REVIEW means the Department or the Department's contractor review after
services and supports are provided to ensure the Client received services
according to the PCSP and that the Case Management Agency complied with the
requirements set forth in statue, waiver and regulation.
MM. SUPPORT is any task performed for the
Client where learning is secondary or incidental to the task itself or an
adaptation is provided.
NN.
TARGETED CASE MANAGEMENT (TCM) means case management services provided to
individuals enrolled in the HCBS-CES, HCBS- Children Habilitation Residential
Program (CHRP), HCBS-DD, and HCBS-SLS waivers in accordance with Section 8.760
et seq, Targeted case management includes facilitating
enrollment, locating, coordinating and monitoring needed HCBS waiver services
and coordinating with other non-waiver resources, including, but not limited to
medical, social, educational and other resources to ensure non-duplication of
waiver services and the monitoring of effective and efficient provision of
waiver services across multiple funding sources. Targeted case management
includes the following activities; Assessment and periodic Reassessment,
development and periodic revision of a PCSP, referral and related activities,
and monitoring.
OO. THIRD PARTY
RESOURCES means services and supports that a Client may receive from a variety
of programs and funding sources beyond natural supports or Medicaid. They may
include, but are not limited to community resources, services provided through
private insurance, nonprofit services and other government programs.
PP. UTILIZATION REVIEW CONTRACTOR (URC) means
the agency contracted with the Department to review the HCBS-CES waiver
applications for determination of eligibility based on the additional targeting
criteria.
QQ. WAIVER SERVICE means
optional services defined in the current federally approved waivers and do not
include Medicaid State Plan benefits.
8.503.10 HCBS-CES WAIVER ADMINISTRATION
A. This section hereby
incorporates the terms and provisions of the federally approved Home and
Community-based Services-Children's Extensive Support (HCBS-CES) waiver
CO.4180.R03.00. To the extent that the terms of that federally approved waiver
are inconsistent with the provisions of this section, the waiver will
control
B. HCBS-CES waiver for
Clients ages birth through seventeen years of age with Developmental Delays or
disabilities is administered through the designated Operating Agency.
C. HCBS-CES waiver services shall be provided
in accordance with the federally approved HCBS-CES waiver document and these
rules and regulations.
D. HCBS-CES
waiver services are available only to address needs identified in the
Functional Needs Assessment and authorized in the Service Plan and when the
service or Support is not available through the Medicaid State Plan, EPSDT,
Natural Supports, or third party payment sources.
E. HCBS-CES waiver:
1. Shall not constitute an entitlement to
services from either the Department or its agents;
2. Shall be subject to annual appropriations
by the Colorado General Assembly;
3. Shall limit the utilization of the
HCBS-CES waiver based on the federally approved capacity, Cost Containment, the
maximum costs and the total appropriations; and,
4. May limit enrollment when utilization of
the HCBS-CES waiver program is projected to exceed the spending
authority.
8.503.20 GENERAL PROVISIONS
A. The following provisions apply to the HCBS
- CES waiver:
1. HCBS-CES waiver services are
provided as an alternative to ICF-IID services for an eligible Client to assist
the Family to Support the Client in the home and community.
2. HCBS-CES waiver is waived from the
requirements of Section 1902(a) (10) (b) of the Social Security Act concerning
comparability of services. The availability and comparability of services may
not be consistent throughout the state of Colorado.
3. A Client enrolled in the HCBS-CES waiver
shall be eligible for all other Medicaid services for which the Client
qualifies and shall first access all benefits available under the Medicaid
State Plan or Medicaid EPSDT prior to accessing services under the HCBS-CES
waiver. Services received through the HCBS-CES waiver may not duplicate
services available through the Medicaid State Plan.
8.503.30 CLIENT ELIGIBILITY
A. To be eligible for the
HCBS-CES waiver, an individual shall meet the target population criteria as
follows:
1. Is unmarried and less than
eighteen years of age,
2. Be
determined to have a Developmental Disability which includes Developmental
Delay if under five (5) years of age,
3. Can be safely served in the community with
the type and amount of HCBS-CES waiver services available and within the
federally approved capacity and Cost Containment limits of the HCBS-CES
waiver,
4. Meet ICF-IID Level of
Care as determined by the LOC Screen.
5. Meet the Medicaid financial determination
for Long-term Care (LTC) eligibility as specified at Section 8.100 et
seq. and,
6. Reside in an
eligible HCBS-CES waiver setting as defined as the following:
a. With biological, adoptive parent(s), or
legal Guardian,
b. In an
out-of-home placement and can return home with the provision of HCBS-CES waiver
services with the following requirement:
i.
The case manager will work in conjunction with the residential caregiver to
develop a transition plan that includes timelines and identified services or
Supports requested during the time the Client is not residing in the Family
home. The case manager will submit the transition plan to the Department for
approval prior to the start of services.
7. Be determined to meet the Federal Social
Security Administration's definition of disability,
8. Be determined by the Department or its
agent to meet the additional targeting criteria eligibility for HCBS-CES
waiver. The additional targeting criterion includes the following:
a. The individual demonstrates a behavior or
has a medical condition that requires direct human intervention, more intense
than a verbal reminder, redirection or brief observation of status, at least
once every two hours during the day and on a weekly average of once every three
hours during the night. The behavior or medical condition must be considered
beyond what is typically Age Appropriate and due to one or more of the
following conditions:
i. A significant pattern
of self-endangering behavior or medical condition which, without intervention
will result in a life-threatening condition or situation. Significant pattern
is defined as the behavior or medical condition that is harmful to self or
others as evidenced by actual events occurring within the past six (6)
months,
ii. A significant pattern
of serious aggressive behavior toward self, others or property. Significant
pattern is defined as the behavior is harmful to self or others, is evidenced
by actual events occurring within the past six (6) months, or
iii. Constant vocalizations such as
screaming, crying, laughing or verbal threats which cause emotional distress to
caregivers. The term constant is defined as on the average of fifteen (15)
minutes each waking hour.
b. In the instance of an annual Reassessment,
the Reassessment must demonstrate in the absence of the existing interventions
or preventions provided through Medicaid that the intensity and frequency of
the behavior or medical condition would resume to a level that would meet the
criterion listed above.
B. The Client shall maintain eligibility by
meeting the HCBS-CES waiver eligibility as set forth in Section 8.503 and the
following:
1. Receives at least one (1)
HCBS-CES waiver service each calendar month,
2. Is not simultaneously enrolled in any
other HCBS waiver, and
3. Is not
residing in a hospital, nursing facility, ICF-IID, other Institution or
correctional facility.
8.503.40 HCBS-CES WAIVER SERVICES
A. The following services are
available through the HCBS-CES waiver within the specific limitations as set
forth in the federally approved HCBS-CES waiver:
1. Adaptive therapeutic recreational
equipment and fees are services which assist a Client to recreate within the
Client's community. These services include recreational equipment that is
adapted specific to the Client's disability and not those items that a typical
age peer would commonly need as a recreation item.
a. The cost of item shall be above and beyond
what is typically expected for recreation and recommended by a doctor or
therapist.
b. Adaptive therapeutic
recreational equipment may include adaptive bicycle, adaptive stroller,
adaptive toys, floatation collar for swimming, various types of balls with
internal auditory devices and other types of equipment appropriate for the
recreational needs of a Client with a Developmental Disability.
c. A pass for admission to recreation centers
for the Client only when the pass is needed to access a professional service or
to achieve or maintain a specific therapy goal as recommended and supervised by
a doctor or therapist. Recreation passes shall be purchased as day passes or
monthly passes, whichever is the most cost effective.
d. Adaptive therapeutic recreation fees
include those for water safety training.
e. The following items are specifically
excluded under HCBS-CES waiver and not eligible for reimbursement:
i. Entrance fees for zoos,
ii. Museums,
iii. Butterfly pavilion,
iv. Movie, theater, concerts,
v. Professional and minor league sporting
events,
vi. Outdoors play
structures,
vii. Batteries for
recreational items; and,
viii.
Passes for Family admission to recreation centers.
f. The maximum annual allowance for adaptive
therapeutic recreational equipment and fees is one thousand (1,000.00) dollars
per Service Plan year.
2.
Assistive technology includes services, Supports or devices that assist a
Client to increase maintain or improve functional capabilities. This may
include assisting the Client in the selection, acquisition, or use of an
assistive technology device and includes:
a.
The evaluation of the assistive technology needs of a Client, including a
functional evaluation of the impact of the provision of appropriate assistive
technology and appropriate services to the Client in the customary environment
of the Client,
b. Services
consisting of selecting, designing, fitting, customizing, adapting, applying,
maintaining, repairing, or replacing assistive technology devices,
c. Training or technical assistance for the
Client, or where appropriate, the Family members, Guardians, caregivers,
advocates, or authorized representatives of the Client,
d. Warranties, repairs or maintenance on
assistive technology devices purchased through the HCBS-CES waiver,
and
e. Adaptations to computers, or
computer software related to the Client's disability. This specifically
excludes cell phones, pagers, and internet access unless prior authorized in
accordance with the Operating Agency's procedures.
f. Assistive technology devices and services
are only available when the cost is higher than typical expenses and are
limited to the most cost effective and efficient means to meet the need and are
not available through the Medicaid State Plan or third-party
resource.
g. Assistive technology
recommendations shall be based on an assessment provided by a qualified
provider within the provider's scope of practice.
h. When the expected cost is to exceed two
thousand five hundred (2,500) dollars per device three estimates shall be
obtained and maintained in the case record.
i. Training and technical assistance shall be
time limited, goal specific and outcome focused.
j. The following items and services are
specifically excluded under HCBS-CES waiver and not eligible for reimbursement:
i. Purchase, training or maintenance of
service animals,
ii.
Computers,
iii. In home installed
video monitoring equipment,
iv.
Medication reminders,
v. Hearing
aids,
vi. Items or devices that are
generally considered to be entertainment in nature including but not limited to
CDs, DVDs, iTunes®, any type of games,
vii. Training, or adaptation directly related
to a school or home educational goal or curriculum; or
viii. Items considered as typical toys for
children.
k. The total
cost of home accessibility adaptations, vehicle modifications, and assistive
technology shall not exceed ten thousand (10,000) dollars over the five (5)
year life of the HCBS-CES waiver without an exception granted by the
Department. Costs that exceed this limitation may be approved for services,
items or devices to ensure the health and safety of the Client or that enable
the Client to function with greater independence in the home or decrease the
need for paid assistance in another HCBS-CES waiver service on a long-term
basis. Requests for an exception shall be prior authorized in accordance with
the Department's procedures and the Department shall respond to exception
requests within thirty (30) days of receipt.
3. Community connector services are intended
to provide assistance to the Client to enable the Client to integrate into the
Client's residential community and access naturally occurring resources.
Community connector services shall:
a. Support
the abilities and skills necessary to enable the Client to access typical
activities and functions of community life such as those chosen by the general
population.
b. Utilize the
community as a learning environment to assist the Client to build relationships
and Natural Supports in the Client's residential community.
c. Be provided to a single Client in a
variety of settings in which Clients interact with individuals without
disabilities, and
d. The cost of
admission to professional or minor league sporting events, movies, theater,
concert tickets or any activity that is entertainment in nature or any food or
drink items are specifically excluded under the HCBS-CES waiver and shall not
be reimbursed.
4.
Hippotherapy includes a therapeutic treatment strategy that uses the movement
of the horse to assist in the development or enhancement of skills including
gross motor, sensory integration, attention, cognitive, social, behavior and
communication.
a. Hippotherapy is provided by
a licensed, certified, registered or accredited professional and the
intervention is related to an identified medical or behavioral need.
Hippotherapy can be reimbursed only when:
i.
The provider is licensed, certified, registered or accredited by an appropriate
national accreditation association in the profession;
ii. The intervention is related to an
identified medical or behavioral need; and
iii. The Medicaid State Plan therapist or
physician identifies the need for the service, establishes the goal for the
treatment and monitors the progress of that goal at least quarterly.
b. The following items are
excluded under the HCBS-CES waiver and are not eligible for reimbursement:
i. Equine therapy,
ii. Therapeutic riding; and,
iii. Experimental treatments or
therapies.
8.503.40.A.5. HOME ACCESSIBILITY ADAPTATIONS
8.503.40.A.5.a DEFINITIONS
Case Management Agency (CMA) means a public or private not-for-profit or for-profit agency that meets all applicable state and federal requirements and is certified by the Department to provide case management services for specific Home and Community-based Services waivers pursuant to Sections 25.5-10-209.5 and 25.5-6-106, C.R.S. and pursuant to a provider participation agreement with the state Department.
Case Manager means a person who provides case management services and meets all regulatory requirements for case managers.
The Division of Housing (DOH) is a division within the Colorado Department of Local Affairs that is responsible for approving Home Accessibility Adaptation PARs, oversight on the quality of Home Accessibility Adaptation projects, and inspecting Home Accessibility Adaptation projects, as described in these regulations
2. DOH
oversight is contingent and shall not be in effect until approved by the
Centers for Medicare and Medicaid Services (CMS). Until approved by CMS, all
oversight functions shall be performed by the Department unless specifically
allowed by the Participant or their guardian to be performed by DOH.
Home Accessibility Adaptations means the most cost-effective physical modifications, adaptations, or improvements in a Participant's existing home setting which, based on the Participant's medical condition or disability:
1. Are necessary to ensure
the health and safety of the Participant, or
2. Enable the Participant to function with
greater independence in the home, or
3. Prevent institutionalization or support
the deinstitutionalization of the Participant.
Home Accessibility Adaptation Provider means a provider agency that meets all the standards for Home Accessibility Adaptation described in Section 8.503.A.5.e and is an enrolled Medicaid provider.
Person-Centered Planning means Home Accessibility Adaptations that are agreed upon through a process that is driven by the Participant and can include people chosen by the Participant, as well as the appropriate health care professionals, providers, and appropriate state and local officials or organizations; and where the Participant is provided necessary information, support, and choice Participant to ensure that the Participant directs the process to the maximum extent possible.
8.503.40.A.5.b
INCLUSIONS
8.503.40.A.5.b.i. Home Accessibility
Adaptations may include, but are not limited to, the following:
a) Installing or building ramps;
b) Installing grab-bars or other Durable
Medical Equipment (DME) if such installation cannot be performed by a DME
supplier;
c) Widening or
modification of doorways;
d)
Modifying a of bathroom facility for the purposes of accessibility, health and
safety, and independence in Activities of Daily Living;
e) Modifying a kitchen for purposes of
accessibility, health and safety, and independence in Activities of Daily
Living;
d) Installing specialized
electric and plumbing systems that are necessary to accommodate medically
necessary equipment and supplies;
g) Installing stair lifts or vertical
platform lifts;
h) Modifying an
existing second exit or egress window to lead to an area of rescue for
emergency purposes;
i) The modification of a
second exit or egress window must be approved by the Department or DOH at any
funding level as recommended by an occupational or physical therapist (OT/PT)
for the health, safety, and welfare, of the Participant.
i) Safety enhancing supports such as basic
fences, strengthened windows, and door and window alerts.
8.503.40.A.5.b.ii Previously completed Home
Accessibility Adaptations, regardless of original funding source, shall be
eligible for maintenance or repair within the Participant's remaining funds
while remaining subject to all other requirements of Section
8.503.40.A.5.
8.503.40.A.5.b.iii
All adaptations, modifications, or improvements must be the most cost-effective
means of meeting the Participant's identified need.
8.503.40.A.5.b.iv Adaptations, modifications,
or improvements to rental properties should be portable and able to move with
the Participant whenever possible.
8.503.40.A.5.b.v The combined cost of Home
Accessibility Adaptations, Vehicle Modifications, and Assistive Technology
shall not exceed $10,000 per Participant over the five-year life of the waiver.
a) Costs that exceed this cap may be approved
by the Department or DOH to ensure the health, and safety of the Participant,
or enable the Participant to function with greater independence in the home,
if:
i) The adaptation decreases the need for
paid assistance in another waiver service on a long-term basis, and
ii) Either:
1. There is an immediate risk to the
Participant's health or safety, or
2. There has been a significant change in the
Participant's needs since a previous Home Accessibility Adaptation.
b) Requests to exceed
the limit shall be prior authorized in accordance with all other Department
requirements found in this rule section
8.503.A.5.
8.503.40.A.5.c
EXCEPTIONS AND
RESTRICTIONS
8.503.40.A.5.c.i Home
Accessibility Adaptations must be a direct benefit to the Participant and not
for the benefit or convenience of caregivers, family Participants, or other
residents of the home.
8.503.40.A.5.c.ii Duplicate adaptations, such
as adaptations to multiple bathrooms within the same home, are
prohibited.
8.503.40.A.5.c.iii
Adaptations, improvements, or modifications as a part of new construction costs
are prohibited.
a) Finishing unfinished areas
in a home to add to or complete habitable square footage is
prohibited.
b) Adaptations that add
to the total square footage of the home are excluded from this benefit except
when necessary to complete an adaptation to:
i) improve entrance or egress to a residence;
or,
ii) configure a bathroom to
accommodate a wheelchair.
c) Any request to add square footage to the
home must be approved by the Department or DOH and shall be prior authorized in
accordance with Department procedures.
8.503.40.A.5.c.iv The purchase of items
available through the Durable Medical Equipment (DME) benefit is
prohibited.
8.503.40.A.5.c.v.
Adaptations or improvements to the home that are considered to be on-going
homeowner maintenance and are not related to the Participant's individual
ability and needs are prohibited.
8.503.40.A.5.c.vi. Upgrades beyond what is
the most cost-effective means of meeting the Participant's identified need,
including, but not limited to, items or finishes required by a Homeowner
Association's (HOA), items for caregiver convenience, or any items and finishes
beyond the basic required to meet the need, are prohibited.
8.503.40.A.5.c.vii. The following items are
specifically excluded from Home Accessibility Adaptations and shall not be
reimbursed:
a) Roof repair,
b) Central air conditioning,
c) Air duct cleaning,
d) Whole house humidifiers,
e) Whole house air purifiers,
f) Installation and repair of driveways and
sidewalks, unless the most cost-effective means of meeting the identified
need,
g) Monthly or ongoing home
security monitoring fees,
h) Home
furnishings of any type,
i) HOA
fees.
8.503.40.A.5.c.viii. Home Accessibility
Adaptation projects are prohibited in any type of certified or non-certified
congregate facility, including, but not limited to, Assisted Living Residences,
Nursing Facilities, Group Homes, Host Homes, and any settings where
accessibility or safety modifications to the location are included in the
provider reimbursement.
8.503.40.A.5.c.ix. If a Participant lives in
a property where adaptations, improvements, or modifications as a reasonable
accommodation through federally funded assisted housing are required by Section
504 of the Rehabilitation Act of 1973, the Fair Housing Act, or any other
federal, state, or local funding, the Participant's Home Accessibility
Adaptation funds may not be used unless reasonable accommodations have been
denied.
8.503.40.A.5.c.x. The
Department may deny requests for Home Accessibility Adaptation projects that
exceed usual and customary charges or do not meet local building requirements,
the 2018 Home Modification Benefit Construction Specifications developed by the
Division of Housing (DOH), or industry standards. The Home Modification Benefit
Construction Specifications (2018) are hereby incorporated by reference. The
incorporation of these guidelines excludes later amendments to, or editions of,
the referenced material. The 2018 Home Modification Benefit Construction
Specifications can be found on the Department website. Pursuant to Sect
24-4-103 (12.5), C.R.S., the
Department maintains copies of this incorporated text in its entirety,
available for public inspection during regular business hours at: Colorado
Department of Health Care Policy and Financing, 1570 Grant Street, Denver
Colorado 80203. Certified copies of incorporated materials are provided at cost
upon request.
8.503.40.A.5.d
CASE MANAGEMENT AGENCY
RESPONSIBILITIES
8.503.40.A.5.d.i. The
Case Manager shall consider alternative funding sources to complete the Home
Accessibility Adaptation. These alternatives considered and the reason they are
not available shall be documented in the case record.
1) The Case Manager must confirm that the
Participant is unable to receive the proposed adaptations, improvements, or
modifications as a reasonable accommodation through federally funded assisted
housing as required by section 504 of the Rehabilitation Act of 1973, the Fair
Housing Act, or any other federal, state, or local funding. Case Managers may
request confirmation of a property owner's obligations through
DOH.
8.503.40.A.5.d.ii.
The Case Manager may prior authorize Home Accessibility Adaptation projects
estimated at less than $2,500 without DOH or Department approval, contingent on
Participant approval and confirmation of Home Accessibility Adaptation fund
availability.
8.503.40.A.5.d.iii.
The Case Manager shall obtain prior approval by submitting a Prior
Authorization Request form (PAR) to DOH for Home Accessibility Adaptation
projects estimated above $2,500.
1) The Case
Manager must submit the required PAR and all supporting documentation according
to Department prescribed processes and procedures found in this rule section
8.503.40.A.5. Home Accessibility Adaptations submitted with improper
documentation will not be approved.
2) The Case Manager and CMA are responsible
for retaining and tracking all documentation related to a Participant's Home
Accessibility Adaptation funding use and communicating that information to the
Participant and Home Accessibility Adaptation providers. The Case Manager may
request confirmation of a Participant's Home Accessibility Adaptation fund use
from the Department or DOH.
3) The
Case Manager shall discuss any potential plans to move to a different residence
with the Participant or their guardian and advise them on the most prudent
utilization of available funds.
8.503.40.A.5.d.iv. Home Accessibility
Adaptations estimated to cost $2,500 or more shall be evaluated according to
the following procedures:
1) An occupational
or physical therapist (OT/PT) shall assess the Participant's needs and the
therapeutic value of the requested Home Accessibility Adaptation. When an OT/PT
with experience in Home Accessibility Adaptation is not available, a
Department-approved qualified individual may be substituted. An evaluation
specifying how the Home Accessibility Adaptation would contribute to a
Participant's ability to remain in or return to his/her home, and how the Home
Accessibility Adaptation would increase the individual's independence and
decrease the need for other services, shall be completed before bids are
solicited. This evaluation shall be submitted with the PAR.
a) The evaluation must be performed in the
home to be modified. If the Participant is unable to access the home to be
modified without the modification, the OT/PT must evaluate the Participant and
home separately and document why the Participant was not able to be evaluated
in the home.
2) The
evaluation may be provided by a home health agency or other qualified and
approved OT/PT through the Medicaid Home Health benefit.
a) A Case Manager may initiate the OT/PT
evaluation process before the Participant has been approved for waiver
services, as long as the Participant is Medicaid eligible.
b) A Case Manager may initiate the OT/PT
evaluation process before the Participant physically resides in the home to be
modified, as long as the current property owner agrees to the
evaluation.
c) OT/PT evaluations
performed by non-enrolled Medicaid providers may be accepted when an enrolled
Medicaid provider is not available. A Case Manager must document the reason why
an enrolled Medicaid provider is not available.
3) The Case Manager and the OT/PT shall
consider less expensive alternative methods of addressing the Participant's
needs. The Case Manager shall document these alternatives and why they did not
meet the Participant's needs in the Participant's case file.
8.503.40.A.5.d.v. The Case Manager
shall assist the Participant in soliciting bids according to the following
procedures:
1) The Case Manager shall assist
the Participant in soliciting bids from at least two Home Accessibility
Adaptation Providers for Home Accessibility Adaptations estimated to cost
$2,500 or more.
2) The Case Manager
must verify that the provider is an enrolled Home Accessibility Adaptation
Provider for Home Accessibility Adaptations.
3) The bids for Home Accessibility
Adaptations at all funding levels shall include a breakdown of the costs of the
project and the following:
a) Description of
the work to be completed.
b)
Description and estimate of the materials and labor needed to complete the
project. Material costs should include price per square foot for materials
purchased by the square foot. Labor costs should include price per
hour.
c) Estimate for building
permits, if needed,
d) Estimated
timeline for completing the project,
e) Name, address and telephone number of the
Home Accessibility Adaptation Provider,
f) Signature, physical or digital, of the
Home Accessibility Adaptation Provider,
g) Signature or other indication of approval,
such as email approval, of the Participant or their guardian, that indicates
all aspects of the bid have been reviewed with them,
h) Signature, physical or digital, of the
homeowner or property manager if the home is not owned by the Participant or
their guardian.
4) Home
Accessibility Adaptation Providers have a maximum of thirty (30) days to submit
a bid for the Home Accessibility Adaptation project after the Case Manager has
solicited the bid.
a) If the Case Manager has
made three attempts to obtain a bid from a Home Accessibility Adaptation
Provider and the provider has not responded within thirty (30) calendar days,
the Case Manager may request approval of one bid. Documentation of the attempts
shall be attached to the PAR.
5) The Case Manager shall submit copies of
the bid(s) and the OT/PT evaluation with the PAR to the Department. The
Department shall authorize the lowest bid that complies with the requirements
found in this rule section 8.503.40.A.5 and the recommendations of the OT/PT
evaluation.
a) If a Participant or home owner
requests a bid that is not the lowest of the submitted bids, the Case Manager
shall request approval by submitting a written explanation with the
PAR.
6) A revised PAR and
Change Order request shall be submitted for any changes from the original
approved PAR according to the procedures found in this rule section
8.503.40.A.5.
8.503.40.A.5.d.vi. If a property to be
modified is not owned by the Participant or their guardian, the Case Manager
shall obtain physical or digital, signatures from the homeowner or property
manager on the submitted bids authorizing the specific modifications described
therein.
1) Written consent of the home owner
or property manager is required for all projects that involve permanent
installation within the Participant's residence or installation or modification
of any equipment in a common or exterior area.
2) The authorization shall include
confirmation that the home owner or property manager agrees that if the
Participant vacates the property, the Participant may choose to either leave
the modification in place or remove the modification, that the home owner or
property manager may not hold any party responsible for removing all or part of
a Home Accessibility Adaptation project, and that if the Participant chooses to
remove the modification, the property must be left in equivalent or better than
its pre-modified condition.
8.503.40.A.5.d.vii. If the CMA does not
comply with the process described above resulting in increased cost for a Home
Accessibility Adaptation, the Department may hold the CMA financially liable
for the increased cost.
8.503.40.A.5.d.vii. The Department or DOH may
conduct on-site visits or any other investigations deemed necessary prior to
approving or denying the Home Accessibility Adaptation PAR.
8.503.40.A.5.e
PROVIDER
RESPONSIBILITIES
8.503.40.A.5.e.i. Home
Accessibility Adaptation Providers shall conform to all general certification
standards and procedures set forth in Section 8.500.98.
8.503.40.A.5.e.ii. Home Accessibility
Adaptation Providers shall be licensed in the city or county in which the Home
Accessibility Adaptation services will be performed, if required by that city
or county.
8.503.40.A.5.e.iii. Home
Accessibility Adaptation Providers shall begin work within sixty (60) days of
signed approval from the Department. Extensions of time may be granted by DOH
or the Department for circumstances outside of the provider's control upon
request by the provider. Requests must be received within the original 60 day
deadline and be supported by documentation, including Participant notification.
Reimbursement may be reduced for delays in accordance with Section
8.503.40.A.5.f.vi.
1) If any changes to the
approved scope of work are made without DOH or Department authorization, the
cost of those changes will not be reimbursed.
2) Projects shall be completed within thirty
(30) days of beginning work. Extensions of time may be granted by DOH or the
Department for circumstances outside of the provider's control upon request by
the provider. Requests must be received within the original 30 day deadline and
be supported by documentation, including Participant notification.
Reimbursement may be reduced for delays in accordance with Section
8.503.40.A.5.f.vi.
8.503.40.A.5.e.iv. The Home Accessibility
Adaptation Provider shall provide a one-year written warranty on materials and
labor from date of final inspection on all completed work and perform work
covered under that warranty at provider's expense.
1) The Provider shall give the Participant or
their guardian all manufacturer's or seller's warranties on completion of
work.
8.503.40.A.5.e.v.
The Home Accessibility Adaptation Provider shall comply with the Home
Modification Benefit Construction Specifications developed by the DOH, which
can be found on the Department website, and with local, and state building
codes.
8.503.40.A.5.e.vi. A sample
of Home Accessibility Adaptation projects set by the Department shall be
inspected upon completion by DOH, a state, local or county building inspector
in accordance with state, local, or county procedures, or a licensed engineer,
architect, contractor or any other person as designated by the Department. Home
Accessibility Adaptation projects may be inspected by DOH upon request by the
Participant at any time determined to be reasonable by DOH. Participants must
provide access for inspections.
1) DOH shall
perform an inspection within fourteen (14) days of receipt of notification of
project completion for sampled projects, or receipt of a Participant's
reasonable request.
2) DOH shall
produce a written inspection report within the time frame agreed upon in the
Home Accessibility Adaptations work plan that notes the Participant's specific
complaints. The inspection report shall be sent to the Participant, Case
Manager, and provider.
3) Home
Accessibility Adaptation providers must repair or correct any noted
deficiencies within twenty (20) days or the time required by the inspection,
whichever is shorter. Extensions of time may be granted by DOH or the
Department for circumstances outside of the provider's control upon request by
the provider. Requests must be received within the original 20 day deadline and
be supported by documentation, including Participant notification.
Reimbursement may be reduced for delays in accordance with Section
8.503.40.A.5.f.vi.
8.503.40.A.5.e.vii. Copies of building
permits and inspection reports shall be submitted to DOH. In the event that a
permit is not required, the Home Accessibility Adaptation Provider shall
formally attest in their initial bid that a permit is not required. Incorrectly
attesting that a permit is not required shall be a basis for non-payment or
recovery of payment by the Department.
1)
Volunteer work on a Home Accessibility Adaptation project approved by the
Department shall be completed under the supervision of the Home Accessibility
Adaptation Provider as stated on the bid.
a)
Volunteer work must be performed according to Department prescribed processes
and procedures found in this rule section 8.503.40.A.5.
b) Work performed by an unaffiliated party,
such as, but not limited to, volunteer work performed by a friend or family
Participant, or work performed by a private contractor hired by the Participant
or family, must be described and agreed upon, in writing, by the provider
responsible for completing the Home Accessibility Adaptation, according to
Department prescribed processes and procedures found in this rule section
8.503.40.A.5.
8.503.40.A.5.f
REIMBURSEMENT
8.503.40.A.5.f.i Payment for Home
Accessibility Adaptation services shall be the prior authorized amount or the
amount billed, whichever is lower. Reimbursement shall be made in two equal
payments.
8.503.40.A.5.f.ii. The
Home Accessibility Adaptation Provider may submit a claim for an initial
payment of no more than fifty percent of the project cost for materials,
permits, and initial labor costs.
8.503.40.A.5.f.iii. The Home Accessibility
Adaptation Provider may submit a claim for final payment when the Home
Accessibility Adaptation project has been completed satisfactorily as shown by
the submission of the following documentation to DOH:
1) Signed lien waivers for all labor and
materials, including lien waivers from sub-contractors;
2) Required permits;
3) One year written warranty on materials and
labor; and
4) Documentation in the
Participant's file that the Home Accessibility Adaptation has been completed
satisfactorily through:
a) Receipt of the
inspection report approving work from the state, county, or local building,
plumbing, or electrical inspector;
b) Approval by the Participant, guardian,
representative, or other designee;
c) Approval by the home owner or property
manager;
d) A final on-site
inspection report by DOH or its designated inspector; or
e) DOH acceptance of photographs taken both
before and after the Home Accessibility Adaptation.
8.503.40.A.5.f.iv. If DOH notifies
a Home Accessibility Adaptation Provider that an additional inspection is
required, the provider may not submit a claim for final payment until DOH has
received documentation of a satisfactory inspection report for that additional
inspection.
8.503.40.A.5.f.v. The
Home Accessibility Adaptation Provider shall only be reimbursed for materials
and labor for work that has been completed satisfactorily and as described on
the approved Home Accessibility Adaptation Provider Bid form or Home
Accessibility Adaptation Provider Change Order form.
1) All required repairs noted on inspections
shall be completed before the Home Accessibility Adaptation Provider submits a
final claim for reimbursement.
2)
If a Home Accessibility Adaptation Provider has not completed work
satisfactorily, DOH shall determine the value of the work completed
satisfactorily by the provider during an inspection. The provider shall only be
reimbursed for the value of the work completed satisfactorily.
a) A Home Accessibility Adaptation Provider
may request DOH perform one (1) reconsideration of the value of the work
completed satisfactorily. This request may be supported by an independent
appraisal of the work, performed at the provider's expense.
8.503.40.A.5.f.vi.
Reimbursement may be reduced at a rate of 1% (one percent) of the total project
amount every seven (7) calendar days beyond the deadlines required for project
completion, including correction of all noted deficiencies in the inspection
report.
1) Extensions of time may be granted
by DOH or the Department for circumstances outside of the provider's control
upon request by the provider. Requests must be received within the original 7
day deadline and be supported by documentation, including Participant
notification.
2) The Home
Accessibility Adaptation reimbursement reduced pursuant to this subsection
shall be considered part of the Participant's remaining funds.
8.503.40.A.5.f.vii. The Home
Accessibility Adaptation Provider shall not be reimbursed for the purchase of
DME available as a Medicaid state plan benefit to the Participant. The Home
Accessibility Adaptation Provider may be reimbursed for the installation of DME
if such installation is outside of the scope of the Participant's DME benefit.
6. Homemaker services
are provided in the Client's home and are allowed when the Client's disability
creates a higher volume of household tasks or requires that household tasks are
performed with greater frequency. There are two types of homemaker services:
a. Basic homemaker services include cleaning,
completing laundry, completing basic household care or maintenance within the
Client's primary residence only in the areas where the Client frequents.
i. This assistance may take the form of
hands-on assistance by actually performing a task for the Client or cueing to
prompt the Client to perform a task.
ii. Lawn care, snow removal, air duct
cleaning and animal care are specifically excluded under HCBS-CES waiver and
shall not be reimbursed.
b. Enhanced homemaker services include basic
homemaker services with the addition of either procedures for habilitation or
procedures to perform extraordinary cleaning.
i. Habilitation services shall include direct
training and instruction to the Client in performing basic household tasks
including cleaning, laundry, and household care which may include some hands-on
assistance by actually performing a task for the Client or enhanced prompting
and cueing.
ii. The provider shall
be physically present to provide step by step verbal or physical instructions
throughout the entire task:
1). When such
Support is incidental to the habilitative services being provided,
2). To increase independence of the
Client,
c.
Incidental basic homemaker service may be provided in combination with enhanced
homemaker services; however, the primary intent must be to provide habilitative
services to increase independence of the Client.
d. Extraordinary cleaning are those tasks
that are beyond routine sweeping, mopping, laundry or cleaning and require
additional cleaning or sanitizing due to the Client's
disability.
7. Massage
therapy includes the physical manipulation of muscles to ease muscle
contractures or spasms, increase extension and muscle relaxation and decrease
muscle tension and includes WATSU.
a. Massage
therapy is provided by a licensed, certified, registered or accredited
professional and the intervention is related to an identified medical or
behavioral need. Massage therapy is reimbursed only when:
i. The provider is licensed, certified,
registered or accredited by an appropriate national accreditation association
in the profession;
ii. The
intervention is related to an identified medical or behavioral need;
and
iii. The Medicaid State Plan
therapist or physician identifies the need for the service, establishes the
goal for the treatment and monitors the progress of that goal at least
quarterly.
b. The
following items are excluded under the HCBS-CES waiver and are not eligible for
reimbursement:
i. Acupuncture,
ii. Chiropractic care, and,
iii. Experimental treatments or
therapies.
8.
Movement therapy includes the use of music therapy and/ or dance therapy as a
therapeutic tool for the habilitation, rehabilitation and maintenance of
behavioral, developmental, physical, social, communication, or gross motor
skills and assists in pain management and cognition.
a. Movement therapy is provided by a
licensed, certified, registered or accredited professional and the intervention
is related to an identified medical or behavioral need and Movement therapy can
be reimbursed only when:
i. The provider is
licensed, certified, registered or accredited by an appropriate national
accreditation association in the profession;
ii. The intervention is related to an
identified medical or behavioral need; and,
iii. The Medicaid State Plan therapist or
physician identifies the need for the service, establishes the goal for the
treatment and monitors the progress of that goal at least quarterly.
b. The following items are
excluded under the HCBS-CES waiver and are not eligible for reimbursement:
i. Fitness training (personal
trainer),
ii. Warm water
therapy,
iii. Experimental
treatments or therapies, and
iv.
Yoga.
9. Parent
education provides unique opportunities for parents or other care givers to
learn how to Support the child's strengths within the context of the child's
disability and enhances the parent's ability to meet the special needs of the
child. Parent education includes:
a.
Consultation and direct service costs for training parents and other caregivers
in techniques to assist in caring for the Client's needs, including sign
language training,
b. Special
resource materials,
c. Cost of
registration for parents or caregivers to attend conferences or educational
workshops that are specific to the Client's disability, and
d. Cost of membership to parent Support or
information organizations and publications designed for parents of children
with disabilities.
e. The maximum
service limit for parent education is one thousand (1,000) units per Service
Plan year.
f. The following items
are specifically excluded under the HCBS-CES waiver and not eligible for
reimbursement:
i. Transportation,
ii. Lodging,
iii. Food, and
iv. Membership to any political organizations
or any organization involved in lobby activities.
10. Respite is provided to Clients
on a short-term basis, because of the absence or need for relief of the primary
caregivers of the Client.
a. Respite may be
provided:
i. In the Client's home or a private
residence,
ii. The private
residence of a respite care provider, or
iii. In the community.
b. Respite is to be provided in an Age
Appropriate manner.
i. A Client eleven (11)
years of age and younger, will not receive respite during the time the parent
works, pursues continuing education or volunteers, because this is a typical
expense for all parents of young children.
c. When the cost of care during the time the
parents works is more for an eligible Client, eleven (11) years of age or
younger, than it is for same age peers, then respite may be used to pay the
additional cost. Parents shall be responsible for the basic and typical cost of
child care.
d. Respite may be
provided for siblings, age eleven (11) and younger, who reside in the same home
of an eligible Client when supervision is needed so the primary caretaker can
take the Client to receive a state plan benefit or a HCBS-CES waiver
service.
e. Respite shall be
provided according to an individual or group rates as defined below:
i. Individual: the Client receives respite in
a one-on-one situation. There are no other Clients in the setting also
receiving respite services. Individual respite occurs for ten (10) hours or
less in a twenty-four (24)-hour period.
ii. Individual day: the Client receives
respite in a one-on-one situation for cumulatively more than ten (10) hours in
a twenty-four (24)-hour period. A full day is ten (10) hours or greater within
a twenty-four (24)- hour period.
iii. Overnight group: the Client receives
respite in a setting which is defined as a facility that offers twenty-four
(24)-hour supervision through supervised overnight group accommodations. The
total cost of overnight group within a twenty-four (24)-hour period shall not
exceed the respite daily rate.
iv.
Group: the Client receives care along with other individuals, who may or may
not have a disability. The total cost of group within a twenty-four (24)-hour
period shall not exceed the respite daily rate. The following limitations to
respite service shall apply:
1) Sibling care
is not allowed for care needed due to parent's work, volunteer, or education
schedule or for parental relief from care of the sibling.
f. Federal financial participation
shall not to be claimed for the cost of room and board except when provided, as
part of respite care furnished in a facility approved pursuant to Section 8.602
by the state that is not a private residence.
g. The total amount of respite provided in
one Service Plan year may not exceed an amount equal to thirty (30) day units
and one thousand eight hundred eighty (1,880) individual units. The Department
may approve a higher amount based on a need due to the Client's age, disability
or unique Family circumstances.
h.
Overnight group respite may not substitute for other services provided by the
provider such as Personal Care, Behavioral Services or other services not
covered by the HCBS-CES waiver.
i.
Respite shall be reimbursed according to a unit rate or daily rate whichever is
less. The daily overnight or group respite rate shall not exceed the respite
daily rate.
j. The purpose of
respite is to provide the primary caregiver a break from the ongoing daily care
of a Client. Therefore, additional respite units beyond the service limit will
not be approved for Clients who receive skilled nursing, certified nurse aid
services, or home care allowance from the primary
caregiver.
11.
Specialized medical equipment and supplies include devices, controls, or
appliances that are required due to the Client's disability and that enable the
Client to increase the Client's ability to perform Activities of Daily Living
or to safely remain in the home and community. Specialized Medical Equipment
and Supplies include:
a. Kitchen equipment
required for the preparation of special diets if this results in a cost savings
over prepared foods;
b. Specially
designed clothing for a Client if the cost is over and above the costs
generally incurred for a Client's clothing;
c. Maintenance and upkeep of specialized
medical equipment purchased through the HCBS-CES waiver.
d. The following items are specifically
excluded under the HCBS-CES waiver and not eligible for reimbursement:
i. Items that are not of direct medical or
remedial benefit to the Client, vitamins, food supplements, any food items,
prescription or over the counter medications, topical ointments, exercise
equipment, hot tubs, water walkers, resistance water therapy pools,
experimental items and wipes for any purpose other than incontinence.
12. Vehicle
modifications are adaptations or alterations to an automobile or van that is
the Client's primary means of transportation, to accommodate the special needs
of the Client, are necessary to enable the Client to integrate more fully into
the community and to ensure the health and safety of the Client.
a. Upkeep and maintenance of the
modifications are allowable services.
b. Items and services specifically excluded
from reimbursement under the HCBS-CES waiver include:
i. Adaptations or improvements to the vehicle
that are not of direct medical or remedial benefit to the Client,
ii. Purchase or lease of a vehicle,
and
iii. Typical and regularly
scheduled upkeep and maintenance of a vehicle.
c. The total cost of Home accessibility
adaptations, vehicle modifications, and assistive technology shall not exceed
ten thousand (10,000) dollars over the five (5) year life of the HCBS-CES
waiver without an exception granted by the Department. Costs that exceed this
limitation may be approved for services, items or devices to ensure the health
and safety of the Client, to enable the Client to function with greater
independence in the home, or to decrease the need for paid assistance in
another HCBS-CES waiver service on a long-term basis. Approval for a higher
amount will include a thorough review of the current request as well as past
expenditures to ensure Cost Effectiveness, prudent purchases and no unnecessary
duplication.
13. Youth
Day
a. Youth day service is the care and
supervision of Clients ages 12 through 17 while the primary caregiver works,
volunteers, or seeks employment.
b.
Youth day service may be provided in the residence of the Client, youth day
service provider, or in the community.
c. Youth day service shall be provided
according to an individual or group rate as defined below:
i. Individual: The Client receives youth day
services with a staff ratio of 1:1, billed at a 15-minute unit. There are no
other youth in the setting also receiving youth day service, respite or
third-party supervision.
ii. Group:
The Client receives supervision in a group setting with other individuals who
may or may not have a disability. Reimbursement is limited to the
Client.
d. Limitations:
i. This service is limited to Clients ages 12
through 17.
ii. This service may
not substitute for or supplant special education and related services included
in a Client's Individualized Education Plan (IEP) developed under Part B of the
Individuals with Disabilities Education Act, 20 U.S.cC. § 1400 (2011).
This includes after school care provided through any education system and
funded through any education system for any student.
iii. This service may not be used to cover
any portion of the cost of camp.
iv. This service is limited to ten (10) hours
per calendar day.
8.503.50 SERVICE PLAN.
The case management agency shall complete a service plan for each Client enrolled in the HCBS-CES waiver in accordance with Section 8.519.11.B.2.
8.503.60 WAITING LIST PROTOCOL
A. When
the HCBS-CES waiver reaches capacity for enrollment, a Client determined
eligible for HCBS-CES waiver benefits shall be placed on a statewide waiting
list in accordance with these rules and the Department's procedures.
1. The Community Centered Board shall
determine if an Applicant has Developmental Delay if under age five (5), or
Developmental Disability if over age five (5), prior to submitting the HCBS-CES
waiver application to the Department or its agent. Only a Client who is
determined to have a Developmental Delay or Developmental Disability may apply
for HCBS-CES waiver.
2. In the
event a Client who has been determined to have a Developmental Delay is placed
on the wait list prior to age five (5), and that Client turns five (5) while on
the HCBS-CES waiver wait list, a determination of Developmental Disability must
be completed in order for the Client to remain on the wait list.
3. The Case Management Agency shall complete
the LOC Screen as defined in Department rules, to determine the Client's Level
of Care.
4. The Case Management
Agency shall complete the HCBS-CES waiver application (for use with the ULTC
100.2 only) with the participation of the Family. The completed application and
a copy of the LOC Screen that determines the Client meets the ICF-IID Level of
Care shall be submitted to the Department or its agent within fourteen (14)
calendar days of parent signature.
5. Supporting documentation provided with the
HCBS-CES waiver application shall not be older than six (6) months at the time
of submission to the Department or its agent.
6. The Department or its agent shall review
the HCBS-CES waiver application. In the event the Department or its agent needs
additional information; the Case Management Agency shall respond within two (2)
business days of request.
7. Any
Client determined eligible for services under the HCBS-CES waiver when services
are not immediately available within the federally approved capacity limits of
the HCBS-CES waiver, shall be eligible for placement on a single statewide
waiting list in the order in which the Department or its agent received the
eligible HCBS-CES waiver application. Applicants denied program enrollment
shall be informed of the Client's appeal rights in accordance with Section
8.057.
8. The Case Management
Agency will create or update the consumer record to reflect the Client is
waiting for the HCBS-CES waiver with the waiting list date as determined by the
Department or its agent.
8.503.70 ENROLLMENT
A. When an opening becomes available for an
initial enrollment to the HCBS-CES waiver it shall be authorized in the order
of placement on the waiting list. Authorization shall include an initial
enrollment date and the end date for the initial enrollment period.
1. The Case Management Agency shall complete
the HCBS-CES waiver application (with ULTC 100.2 only) and the LOC Screen in
the Family home with the participation of the Family. The completed
application, as applicable, and a copy of the LOC Screen shall be submitted to
the Department or its agent within thirty (30) days of the authorized initial
enrollment date.
a. If it has been less than
six (6) months since the review to determine waiting list eligibility by the
URC and there has been no change in the Client's condition, the Case Management
Agency shall complete the LOC Screen and the parent may submit a letter to the
Case Management Agency in lieu of the HCBS-CES waiver application stating there
has been no change.
b. If there has
been any change in the Client's condition the Case Management Agency shall
complete a LOC Screen and the HCBS-CES waiver application, as applicable, which
shall be submitted to the Department or its agent.
2. Services and Supports shall be implemented
pursuant to the PCSP within 90 days of the parent or Guardian
signature.
3. All continued stay
review enrollments shall be completed and submitted to the Department or its
agent at least thirty (30) days and not more than ninety (90) days prior to the
end of the current enrollment period.
8.503.80 CLIENT RESPONSIBILITIES
A. The parent or legal Guardian of a Client
is responsible to assist in the enrollment of the Client and cooperate in the
provision of services. Failure to do so shall result in the Client's
termination from the HCBS-CES waiver. The parent or legal Guardian shall:
1. Provide accurate information regarding the
Client's ability to complete activities of daily living, daily and nightly
routines and medical and behavioral conditions;
2. Cooperate with providers and Case
Management Agency requirements for the HCBS-CES waiver enrollment process,
Reassessment process and provision of services;
3. Cooperate with the local Department of
Human Services in the determination of financial eligibility;
4. Complete the HCBS-CES waiver application
with fifteen (15) calendar days of the authorized initial enrollment date as
determined by the HCBS-CES waiver coordinator or in the event of a
Reassessment, at least thirty (30) days prior to the end of the current
certification period;
5. Complete
the PCSP within thirty (30) calendar days of determination of HCBS-CES waiver
additional targeting criteria eligibility as determined by the Department or
its agent.
6. Notify the case
manager within thirty (30) days after changes:
a. In the Client's Support system, medical
condition and living situation including any hospitalizations, emergency room
admissions, nursing home placements or ICF-IID placements;
b. That may affect Medicaid financial
eligibility such as prompt report of changes in income or resources;
c. When the Client has not received an
HCBS-CES waiver service for one calendar month;
d. In the Client's care needs; and,
e. In the receipt of any HCBS-CES waiver
services.
8.503.90 PROVIDER REQUIREMENTS
A. A private for profit or not for profit
agency or government agency shall ensure that the contractor or employee meets
minimum provider qualifications as set forth in the HCBS-CES waiver and shall:
1. Conform to all state established standards
for the specific services they provide under HCBS-CES waiver,
2. Maintain program approval and
certification from the Department,
3. Maintain and abide by all the terms of
their Medicaid provider agreement with the Department and with all applicable
rules and regulations set forth in Section 8.130,
4. Discontinue HCBS-CES waiver services to a
Client only after documented efforts have been made to resolve the situation
that triggers such discontinuation or refusal to provide HCBS-CES waiver
services,
5. Have written policies
governing access to duplication and dissemination of information from the
Client's records in accordance with state statutes on confidentiality of
information at Section
25.5-1-116, C.R.S.,
6. When applicable, maintain the required
licenses and certifications from the Colorado Department of Public Health and
Environment, and
7. Maintain Client
records to substantiate claims for reimbursement according to Medicaid
standards.
B. HCBS-CES
waiver service providers shall comply with:
1.
All applicable provisions of Article
10 of Title
25.5, C.R.S. and
all rules and regulations as set forth in Section 8.600,
2. All federal and state program reviews or
financial audit of HCBS-CES waiver services,
3. The Department's on-site certification
reviews for the purpose of program approval, ongoing program monitoring or
financial and program audits,
4.
Requests from the County Departments of Human Services to access records of
Clients and to provide necessary Client information to determine and
re-determine Medicaid financial eligibility,
5. Requests by the Department to collect,
review and maintain individual or agency information on the HCBS-CES waiver,
and
6. Requests by the Case
Management Agency to monitor service delivery through targeted case management
activities.
8.503.100 TERMINATION OR DENIAL OF HCBS-CES MEDICAID PROVIDER AGREEMENTS
A. The Department may deny or terminate an
HCBS-CES waiver Medicaid provider agreement when:
1. The provider is in violation of any
applicable certification standard or provision of the provider agreement and
does not adequately respond to a corrective action plan within the prescribed
period of time. The termination shall follow procedures at Section
8.076.
2. A change of ownership
occurs. A change in ownership shall constitute a voluntary and immediate
termination of the existing provider agreement by the previous owner of the
agency and the new owner must enter into a new provider agreement prior to
being reimbursed for HCBS-CES waiver services.
3. The provider or its owner has previously
been involuntarily terminated from Medicaid participation as any type of
Medicaid service provider.
4. The
provider or its owner has abruptly closed, as any type of Medicaid provider,
without proper prior Client notification.
5. The provider fails to comply with
requirements for submission of claims under Section 8.040.2 or after actions
have been taken by the Department, the Medicaid Fraud Control Unit or their
authorized agents to terminate any provider agreement or recover
funds.
6. Emergency termination of
any provider agreement shall be in accordance with procedures at Section
8.076.
8.503.110 ORGANIZED HEALTH CARE DELIVERY SYSTEM
A. The Organized Health
Care Delivery System (OHCDS) for HCBS-CES waiver is the Community Centered
Board as designated by the Department in accordance with Section
25.5-10-209, C.R.S.
1. The OHCDS is the Medicaid provider of
record for a Client whose services are delivered through the OHCDS.
2. The OHCDS shall maintain a Medicaid
provider agreement with the Department to deliver HCBS-CES waiver services
according to the current federally approved waiver.
3. The OHCDS may contract or employ for
delivery of HCBS-CES waiver services.
4. The OCHDS shall:
a. Ensure that the contractor or employee
meets minimum provider qualifications as set forth in the HCBS-CES
waiver,
b. Ensure that services are
delivered according to the HCBS-CES waiver definitions and as identified in the
Client's Service Plan,
c. Ensure
the contractor maintains sufficient documentation to Support the claims
submitted, and
d. Monitor the
health and safety of HCBS-CES waiver Clients receiving services from a
subcontractor.
5. The
OHCDS is authorized to subcontract and negotiate reimbursement rates with
providers in compliance with all federal and state regulations regarding
administrative, claim payment and rate setting requirements. The OCHDS shall:
a. Establish reimbursement rates that are
consistent with efficiency, economy and quality of care,
b. Establish written policies and procedures
regarding the process that will be used to set rates for each service type and
for all providers,
c. Ensure that
the negotiated rates are sufficient to promote quality of care and to enlist
enough providers to provide choice to Clients
d. Negotiate rates that are in accordance
with the Department's established fee for service rate schedule and the
Department's procedures:
i. Manually priced
items that have no maximum allowable reimbursement rate assigned, nor a
Manufacturer's Suggested Retail Price (MSRP), shall be reimbursed at the lesser
of the submitted charges or the sum of the manufacturer's invoice cost, plus
13.56 percent.
e. Collect
and maintain the data used to develop provider rates and ensure data includes
costs for the services to address the Client's needs, that are allowable
activities within the HCBS-CES waiver service definition and that Supports the
established rate, and
f. Maintain
documentation of provider reimbursement rates and make it available to the
Department, its Operating Agency and Centers for Medicare and Medicaid Services
(CMS).
g. Report by August 31 of
each year, the names, rates and total payment made to the
contractor.
8.503.120 PRIOR AUTHORIZATION REQUESTS
Prior Authorization Requests (PAR) shall be in accordance with Section 8.519.14.
8.503.130 RETROSPECTIVE REVIEW PROCESS
A. Services provided to a
Client are subject to a Retrospective Review by the Department or its agent.
This Retrospective Review shall ensure that services:
1. Identified in the Service Plan is based on
the Client's identified needs as stated in the Functional Needs
Assessment,
2. Have been requested
and approved prior to the delivery of services,
3. Provided to a Client are in accordance
with the Service Plan, and
4.
Provided are within the specified HCBS service definition in the federally
approved HCBS-CES waiver.
B. The Case Management Agency or provider
shall be required to submit a plan of correction that is monitored for
completion by the Department or its agent when areas of non-compliance are
identified in the Retrospective Review.
C. The inability of the provider to implement
a plan of correction within the timeframes identified in the plan of correction
may result in temporary suspension of claims payment or termination of the
provider agreement.
D. When the
provider has received reimbursement for services and the review by the
Department or its agent identifies that it is not in compliance with
requirements, the amount reimbursed will be subject to the reversal of claims,
recovery of amount reimbursed, suspension of payments, or termination of the
provider agreement.
8.503.140 PROVIDER REIMBURSEMENT
A. Providers shall submit claims directly to
the Department's fiscal agent through the Medicaid Management Information
System (MMIS) or through a qualified billing agent enrolled with the
Department's fiscal agent.
1. Provider claims
for reimbursement shall be made only when the following conditions are met:
a. Services are provided by a qualified
provider as specified in the federally approved HCBS-CES waiver,
b. Services have been prior
authorized,
c. Services are
delivered in accordance to the frequency, amount, scope and duration of the
service as identified in the Client's Service Plan, and
d. Required documentation of the specific
service is maintained and sufficient to support that the service is delivered
as identified in the Service Plan and in accordance with the service
definition.
2. Provider
claims for reimbursement shall be subject to review by the Department or its
agent. This review may be completed before or after payment has been made to
the provider.
3. When the review
identifies areas of noncompliance, the provider shall be required to submit a
plan of correction that is monitored for completion by the Department or its
agent.
4. When the provider has
received reimbursement for services and the review by the Department or its
agent identifies that the service delivered, or the claims submitted is not in
compliance with requirements, the amount reimbursed will be subject to the
reversal of claims, recovery of amount reimbursed, suspension of payments, or
termination of provider status.
8.503.150 CLIENT RIGHTS
A. Client rights should be in accordance with
Sections 25.5-10-218 through
231, C.R.S.
8.503.160 APPEAL RIGHTS
Case Management Agencies shall meet the requirements set forth at Section 8.519.22
8.503.160.A
The CCB shall provide the long-term care notice of action form to the applicant
and Client's parent or legal guardian within eleven (11) business days
regarding the Client's appeal rights in accordance with Section 8.057
et seq. when:
1. The Client
or applicant is determined not to have a developmental delay or developmental
disability,
2. The Client or
applicant is determined eligible or ineligible for Medicaid LTSS,
3. The Client or applicant is determined
eligible or ineligible for placement on a waiting list for Medicaid
LTSS,
4. An Adverse Action occurs
that affects the Client's or applicant's HCBS-CES waiver enrollment status
through termination or suspension,
8.503.160.B The CCB shall appear and defend
its decision at the Office of Administrative Courts as described in Section
8.057 et seq. when the CCB has made a denial or adverse action against a Client
or applicant.
8.503.160.C The CCB
shall notify the Case Management Agency in the Client's service plan within one
(1) business day of the adverse action.
8.503.160.D The CCB shall notify the County
Department of Human Services income maintenance technician within one (1)
business day of an Adverse Action that affects Medicaid financial
eligibility.
8.503.160.E The CCB
shall inform the applicant's or Client's parent or legal guardian of an adverse
action if the applicant or Client is determined ineligible and the following:
1. The Client or applicant, parent or legal
guardian fails to submit the Medicaid financial application for LTC to the
financial eligibility site within thirty (30) days of LTC referral,
2. A Client, parent or legal guardian fails
to submit financial information for re-determination for LTC to the financial
eligibility site within the required re-determination timeframe,
3. The County Income Maintenance Technician
has determined the Client no longer meets financial eligibility criteria as set
forth in Section 8.100,
4. The
Client cannot be served safely within the cost containment as identified in the
HCBS-CES waiver,
5. The Client
requires twenty-four (24) hour supports provided through Medicaid state
plan,
6. The resulting total cost
of services provided to the Client, including Targeted Case Management, home
health and HCBS-CES waiver services, exceeds the cost containment as identified
in the HCBS-CES waiver,
7. The
Client enters an institution for treatment with duration that continues for
more than thirty (30) days,
8. The
Client is detained or resides in a correctional facility, and
9. The Client enters an institute for mental
illness with a duration that continues for more than thirty (30)
days.
8.503.170 QUALITY ASSURANCE
A. The
monitoring of HCBS-CES waiver services and the health and well-being of service
recipients shall be the responsibility of the Department or its agent.
1. The Department or its agent may conduct
reviews of each agency providing HCBS-CES waiver services or cause to have
reviews to be performed in accordance with guidelines established by the
Department. The review will apply rules and standards developed for programs
serving Clients with developmental disabilities.
2. The provider agency shall maintain or
cause to be maintained for six (6) years a complete file of all records,
documents, communications, and other materials which pertain to the operation
of the HCBS-CES waiver or the delivery of services under the HCBS-CES waiver.
The Department shall have access to these records at any reasonable
time.
3. The Department may deny or
terminate the Medicaid provider agreement for any agency which it finds to be
in violation of applicable standards and which does not adequately respond with
a corrective action plan to the Department within the prescribed period of
time.
Disclaimer: These regulations may not be the most recent version. Colorado may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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