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 2505-10-8.600 - MEDICAL ASSISTANCE - SECTION 8.600 Case Management, Family Support, Laboratory and X-Ray
Section 10 CCR 2505-10-8.603 - PROGRAM APPROVAL BY THE DEPARTMENT

Universal Citation: 2505 CO Code Regs 10 CCR 2505-10-8.603

Current through Register Vol. 47, No. 5, March 10, 2024

A. All service agencies approved by a community centered board to provide comprehensive services shall also be approved by the Department to provide the authorized service(s) for which they have been selected prior to delivery of such services.

The program approved service agency maintains overall responsibility for services provided to a person receiving services. A service agency may, however, arrange with an individual or typical community service agency to provide a portion of the authorized services without the individual or the typical community service agency being approved by the Department when:

1. The program approved service agency is directly involved in the provision of services and supports required by the person due to his/her developmental disabilities; or,

2. The program approved service agency directly provides the majority of services and supports to persons receiving residential, or adult habilitation day services or supports under the HCB-DD Medicaid waiver; or,

3. The services are provided by a host home provider; or,

4. Services are provided by a qualified professional in his/her professional discipline; for example, physical therapy and nursing.

B. A developmental disabilities service agency selected and approved by a community centered board to provide support services shall be approved by the Department prior to the delivery of such services when it is not otherwise approved by the Department within the service area.

C. Each community centered board shall be approved by the Department to provide support services.

D. The community centered board shall recommend to the Department a service agency for program approval and Medicaid certification only if it meets requirements set forth in section 25.5 -10, C.R.S., and rules of the Department.

1. Recommendations for Department program approval shall be made in a manner prescribed by the Department.

2. The Department shall review the application for program approval for completeness and accuracy and act upon the recommendation of the community centered board.

E. Community centered boards and service agencies approved by the Department shall be regularly evaluated by the Department. Evaluations shall be conducted by the Department or, with Department concurrence, the following may be substituted:

1. Accreditation of program approved service agencies providing adult day habilitation services and supports by a national accreditation body acceptable to the Department; or,

2. Licensure, certification or approval acceptable to the Department from another state regulatory body; or,

3. Some combination of the above approaches which provides oversight of both programmatic and safety areas.

F. Program approval shall be renewed when, based on the results of the evaluation, the community centered board or service agency is found to be in substantial compliance with requirements pertaining to the program evaluated.

G. Program approval shall lapse for a service agency not under contract with a community centered board or the Department unless otherwise continued by the Department; and,

H. The Department may revoke program approval upon a finding that the service agency is in violation of section 25.5 -10, C.R.S., other state or federal laws, or these rules.

Revocation shall conform to the provisions and procedures specified in section 24-4-104, C.R.S.

8.603.1 CONTRACTUAL ISSUES BETWEEN COMMUNITY CENTERED BOARD AND PROGRAM APPROVED SERVICE AGENCY REGARDING PERFORMANCE

A. All service agencies are responsible for the services they provide directly. In addition, program approved service agencies are responsible for any services provided through contract.

B. If purchased services and supports fall below the acceptable level of service provision, which shall be determined through on-site review of programs and other monitoring against rules and regulations of the Department, the community centered board shall notify the program approved service agency of its findings and shall provide the agency reasonable opportunity to comply with requirements. The community centered board shall also notify the Department of its findings.

Nothing in this procedure shall prohibit the community centered board from taking appropriate action when necessary to preserve the health, safety or welfare of persons receiving services or the public.

C. Prior to terminating a contract with a program approved service agency, the community centered board must provide the service agency with notice of such action, including documentation of the reasons for such action.

D. Prior to terminating a contract with a program approved service agency the community centered board shall notify the Department of the grounds for termination, including specific instances of failure of the program approved service agency in question to comply with requirements of section 25.5-10-101, C.R.S., et seq., and these rules.

8.603.2 DISPUTE RESOLUTION PROCESS BETWEEN COMMUNITY CENTERED BOARD AND PROGRAM APPROVED SERVICE AGENCY FOR THE NON-RENEWAL OF AN EXISTING CONTRACT

A. The community centered board shall establish procedures and timeframes which provide reasonable notice, at a minimum thirty (30) days, to a service agency in the event it decided not to renew a contract with the program approved service agency.

B. The program approved service agency whose contract the community centered board has decided not to renew shall be provided an opportunity to present its concerns by first protesting the non-renewal to the community centered board.

1. The community centered board shall provide a written response to the program approved service agency within fifteen (15) days of the service agency protesting the non-renewal of a contract.

2. As soon as possible after reaching the decision not to renew, the community centered board shall send notice as defined in section 8.600.4 to all affected individuals.

3. The community centered board shall inform the Department of any decision to not renew a contract with a program approved service agency. Within seven (7) days the Department may:

a. Require a transition plan for providing services to the affected individuals;

b. Require that any additional information, as defined by the Department, be sent to all affected individuals; and,

c. Require that the community centered board and program approved service agency mediate the dispute.

8.603.3 FISCAL AND PERSONNEL ADMINISTRATION

Medicaid-funded services for persons with developmental disabilities are administered by the Colorado Department of Health Care Policy and Financing.

8.603.4 CONTRACTS/WRITTEN AGREEMENTS

A. Contracts between the Department and community centered boards or service agencies for services for persons with developmental disabilities shall comply with the contractual requirements of Chapter 3 of the State Fiscal Rules promulgated pursuant to section 24-30-202, C.R.S.

B. Contracts between the community centered board and program approved service agencies, as identified in section 8.603 of these rules, must be current and signed prior to the delivery of services. Contracts must contain any state prescribed provisions and, at a minimum, address the following:

1. The amount, duration, and scope of services to be provided.

2. The rate at which the listed services are to be reimbursed.

3. A clause stipulating the listed services are not assignable.

4. The requirements regarding submission of service provision and billing information.

5. A clause stipulating the requirement for comprehensive general liability insurance to be in effect at all times.

6. A clause specifying the requirements for cancellation of the contract by either party.

7. Actions that may be taken in situations involving suspected or alleged mistreatment, abuse, neglect or exploitation to protect the safety of the person receiving services pursuant to section 8.608.8.

C. Agreements between the community centered board or a program approved service agency and other service agencies must be in writing and signed prior to the delivery of services. Written agreements must contain any state prescribed provisions and specific language that at a minimum addresses section 8.603.4.B.1 through 7.

1. All contracts pursuant to 25.5-10-206, C.R.S., must contain the contract provisions specified by the Department. Contracts and written agreements entered into between community centered boards and service agencies may contain contract provisions in addition to those contract provisions specified by the Department. Any such additional provisions shall not contradict the Department's specified provisions nor in any way diminish or alter the provisions of these rules.

2. Contracts for Medicaid-funded services shall be governed by the rules and regulations of the Colorado Department of Health Care Policy and Financing's Medical Assistance Staff Manual (10 C.C.R. 2505-10).

3. A transfer of ownership or operation of a community centered board or a program approved service agency terminates the contract and Medicaid provider certification. In order to participate in the Medicaid program, the new owner or operator of the community centered board or service agency must establish that the program meets the conditions for participation as provided in these rules and enter into a new contract and receive Medicaid provider certification. No payments to the new owner will be made by the community centered board or the State until Medicaid provider certification is granted and applicable licenses are received and a valid contract exists.

8.603.5 PAYMENT FOR SERVICES PURCHASED

A. Services purchased by community centered boards or services agencies under contract with the Department are subject to available appropriations and the amounts specified in the contract.

B. Community centered boards or service agencies under contract with the Department and service agencies under contract with the community centered board shall submit enrollment, attendance data and billing invoices in the format prescribed by the Department.

C. The development and implementation of an Individualized Plan for each eligible person, as set forth herein, is a condition of funding by the Department for services and supports. The Department shall disallow payments to community centered boards, or service agencies under direct contract with the Department, in the amount of funds provided for the eligible person for whom the Individualized Plan has not been developed and implemented for the period of time until an Individualized Plan is developed and implemented.

D. The submission of the LTC-102 form for continued stay reviews is a condition of funding by the Department for services and supports. The Department will disallow payments to the community centered board or service agency under direct contract with the Department, in the amount of funds provided for the eligible person for whom the LTC-102 form has not been submitted.

E. Program approval by the Department is a condition of Departmental funding of community centered boards and service agency programs requiring program approval as identified in section 8.603. The Department shall disallow payments to community centered boards or service agencies in the amount of funds provided for instances when program approval has not been obtained prior to delivery of program services to eligible individuals.

F. The Department shall pay to the community centered board or service agency the amount due within thirty (30) days of presentation of a billing.

G. Payment to the community centered board or service agency shall be made by using the rates established by the Department which are net of any required five percent (5%) local matching funds. Funds that require the five-percent local match will be identified in the contract for purchase of services between the Department and each service agency.

H. Local matching funds include:

1. Funds provided for general operating expenses by any political subdivision of the State;

2. Funds provided for general operating expenses through cash donations or contributions;

3. In-kind goods and services as defined by generally accepted accounting principles and Departmental policies; and,

4. Donations made for a donor-restricted purpose (such as purchase of equipment or property).

I. Local matching funds may be provided by the community centered board or service agency.

When either party provides the local match for the other party, the providing party must certify in writing, for audit purposes, to the other party, the following information:

1. The amount of matching funds;

2. The source of matching funds as described in section 8.603.5.G; and,

3. A statement assuring that these matching funds are not being used to meet the local matching requirement of any other state or federal program.

J. Any community centered board under contract with the Department providing services to persons with developmental disabilities which fails to meet the five percent (5%) match requirements shall document the good faith effort necessary to achieve a ratio of ninety-five percent (95%) state participation and five-percent (5%) local participation. Should the community centered board not show a good faith effort to obtain a five-percent local match, the community centered board will be subject to the administrative penalties identified in the contract with the Department.

K. Reimbursement for Residential Habilitation Services and Supports shall exclude any costs associated with room and board expenses as required by 42 C.F.R. 441.310. The maximum monthly amount charged for room and board expenses to persons receiving comprehensive services by an agency shall not exceed an amount equal to the monthly benefit for Supplemental Security Income (SSI), less an amount specified by the Department for personal needs.

L. Reimbursement for the final month of services provided (not necessarily the final month of a contract period) by a service agency shall be withheld until audits have been completed to determine that no adjustments resulting in moneys due the service agency, the State, or the persons receiving services remain unadjusted. Such reimbursement shall continue to be withheld until all questions and issues raised by the audits are resolved.

M. When providers are paid for Medicaid services based on Medicaid claims submitted by providers, these payments are made on the condition that the providers accept them as payment-in-full for the service and agree not to seek additional reimbursement for the service from the recipient or recipient's family.

Services provided in conjunction with Medicaid reimbursable services that are not themselves Medicaid reimbursable may be billed to recipients and their families.

N. Targeted case management services are only reimbursed for individuals enrolled in the HCBS-DD, Supported Living Services and Children's Extensive Support Waiver Programs. Individuals enrolled in the HCBS-DD waiver who continue to receive comprehensive habilitation services which are not billed to Medicaid because units have been exhausted continue to be eligible for targeted case management services.

O. Failure to prepare the IP and ISSP or failure to submit the IP, ULTC-100 or LTC-102 forms in accordance with Department policies and procedures shall result in the denial of reimbursement for services authorized retroactive to first date of service, and the case management agency and/or providers may not seek reimbursement for these services from the person receiving services.

1. If the community centered board makes an error in billing the Medicaid fiscal agent for services delivered by a sub-contracting service agency, and the error results in loss of Medicaid reimbursement, the community centered board shall reimburse the service agency for the amount of the loss.

2. If the community centered board causes an individual enrolled in Medicaid waiver services to have a break in payment authorization, the community centered board will ensure that all services continue and will be solely financially responsible for any losses incurred by other providers until payment authorization is reinstated.

8.603.6 ACCOUNTING SYSTEMS

A. The community centered board or program approved service agency shall provide for the maintenance and operation of an accounting system that meets the Department's requirements.

B. The community centered board or program approved service agency shall submit financial reports in a format and manner prescribed by the Department, including but not limited to, an annual financial statement prepared in accordance with generally accepted accounting principles and Departmental policies.

8.603.7 AUDITS, FINANCIAL INFORMATION AND BUDGET INFORMATION

A. Each designated Community Centered Board is subject to the requirements of the "Colorado Local Government Audit Law," see section 29-1-601 et seq., C.R,S.

1. Each Community Centered Board shall require the person or entity that performs financial audits of the Community Centered Board to present and discuss the results of the audit to the board of directors not less than once each year at a regularly scheduled meeting of the board of directors.

2. Each completed financial audit shall be posted on The Community Centered Board's website, in a place that allows access to the public in a clear, accessible, easily operated, and uncomplicated manner.

3. Each completed financial audit shall be posted on the website of the Community Centered Board within thirty days of acceptance by the corporation's board of directors. Completed audits shall remain posted on the website for no less than three fiscal years.

B. Each Community Centered Board is subject to a performance audit by the state auditor in accordance with Section 25.5-10-209(4), C.R.S. The Community Centered Board shall cooperate with the performance audit by the state auditor.

C. Each Community Centered Board shall post on their website the most current Form 990 that has been filed with the internal revenue service. Form 990 shall be posted no later than thirty days following the filing of the form with the Internal Revenue Service. Each Form 990 shall remain posted on the website for a minimum of three fiscal years.

D. The Community Centered Board shall make the following information available upon request, not later than five business days after the request is made:

1. The annual budget of the Community Centered Board for each calendar or fiscal year, as applicable, not later than thirty days after final approval of the budget by the board of directors of the Community Centered Board;

2. An annual summary of all revenues and expenditures of the Community Centered Board as have been appropriated by the state concerning capacity building, Family Support Services, State General Fund Supported Living Services, and State General Fund Early Intervention that is calculated by September 30 of each year for the prior year, as applicable; and

3. A description of the policies and procedures it follows to track, manage, and report its financial resources and transactions, which policies and procedures are also known and may be referred to as its "financial controls".

8.603.8 INSURANCE AND LIABILITY COVERAGE

A. Community centered boards and program approved service agencies shall maintain, in force at all times, a comprehensive general liability insurance policy, issued by a company authorized to do business in Colorado in an amount acceptable to the Department as specified by contract for total injuries or damages arising from any one incident, for bodily injuries or damages.

B. Program approved service agencies shall maintain or require to be maintained in force at all times, comprehensive general liability insurance coverage for services that are provided directly by the agency or through contract.

C. The community centered board or a program approved service agency shall obtain and maintain at all times a fidelity bond in an amount acceptable to the Department covering the activities of its officers or agents.

D. Adequate insurance coverage, as required by state law or regulation, for the protection of vehicle fleets, riders and operating personnel, must be provided by anyone transporting persons with disabilities.

E. A community centered board or a program approved service agency managing personal needs funds shall purchase and maintain a surety bond in an amount specified by the Department, or provide an irrevocable letter of credit in the same amount, made payable to the state, to protect the personal needs of the person receiving services.

8.603.9 PERSONNEL AND CONTRACTOR ADMINISTRATION

A. Community centered boards and program approved service agencies shall establish qualifications for employees and contractors (Host Home and other providers) and maintain records documenting the qualifications and training of employees and contractors who provide services pursuant to these rules and regulations.

B. The community centered board or service agency may, in accordance with section 27-90-110, C.R.S., conduct background checks and reference checks prior to employing staff providing supports and services and contracting with Host Home and other providers.

C. The community centered board in its role as support coordinating agency, as defined in section 8.609.1 , shall have screening procedures for individual providers who are not agency employees and for other entities providing services and supports.

D. The community centered board and program approved service agency shall have an organized program of orientation and training of sufficient scope for employees and contractors to carry out their duties and responsibilities efficiently, effectively and competently. The program shall, at a minimum, provide for:

1. Extent and type of training to be provided prior to employees or contractors providing supports and services having unsupervised contact with persons receiving services;

2. Training related to health, safety and services and supports to be provided within the first ninety (90) days for employees and contractors; and,

3. Training specific to the individual(s) for whom the employees or contractors will be providing services and supports.

E. Community centered boards shall ensure that individuals who are hired to fulfill the duties of case management services on or after October 8, 2021 meet the requirements in Section 8.519.5.B.

F. All employees and contractors, not otherwise authorized by law to administer medication, who assist and/or monitor persons receiving services in the administration of medications or the filling of medication reminder systems shall have passed a competency evaluation offered by an approved training entity, as defined in 6 CCR 1011-1, Chapter 24, et seq.

8.603.10 PURCHASE OF SERVICE RATES

A. Annually the Department shall make available a schedule of program rates to be used to purchase non-community centered board specific authorized services for persons with developmental disabilities. The established rates shall be based upon the annual appropriation from the General Assembly, the Department's determination of approved program cost and the 5% local match.

B. Annually, the community centered board shall make available a schedule of program rates and/or rate ranges used in their designated service area to purchase authorized services for persons with developmental disabilities.

C. Administration of community centered board Purchase of Service Rates shall comply with the following:

1. Pursuant to section 25.5-10-206(5), C.R.S., the following rules are provided for the purpose of delineating rates to be used by community centered boards for purchase of services from service agencies for persons receiving services for whom funds have been made available pursuant to section 25.5-10-206(5), C.R.S.

2. The community centered board is authorized to negotiate specific program rates for purchasing services from service agencies. The community centered board must maintain written documentation on how rates were established and paid, and an audit trail of provider expenses to support payments and future rate negotiations. The parameters to be followed in negotiating rates are as follows:

a. Rates must be consistent with efficiency, economy and quality of care.

b. The policy and methods used in setting payment rates must be in writing and consistently applied to all providers including the community centered board as provider.

c. Documentation of payment rates must be maintained and made available upon request.

d. Providers must be given sufficient information concerning the service obligations to assist them in developing cost effective and efficient rate proposals.

3. When a community centered board proposes to charge fees to service agencies for services, the following must be complied with:

a. The board of directors must approve all plans to charge service agencies;

b. The community centered board must provide the service agency with a written description for each service provided and the amount of the proposed fee for each service;

c. The proposed fee to service agencies cannot be established to pay for services otherwise reimbursed, as determined by the Department;

d. Any proposed fee by community centered boards related to managing the billing process must meet the following criteria:

1) The fee must relate to the cost of processing billings;

2) Not be related on a percentage or other basis to the amount that is billed or collected; and,

3) Not be dependent upon the collection of payment;

e. Negotiated fees between community centered boards and service agencies will not be deducted from any payments for services; and,

f. The community centered board will provide the service agencies with statements for services delivered.

4. The community centered board shall establish procedures and reasonable timeframes that provide the opportunity for a service agency to protest the proposed fee charges to the community centered board, and for a timely written response.

5. The community centered board shall inform the service agency of the opportunities to appeal the decision to the Department; and,

6. The community centered board shall submit a copy of all protests and subsequent proceedings to the Department.

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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