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Bottom Line: Coloradans deserve a Community Mental Health Supports Waiver a whole better than this!
Updated Jan. 25, 2017
CO Medicaid Home & Community Based Services -- Community Mental Health Services (CMHS) -- 8.509
8.509 HOME AND COMMUNITY BASED SERVICES FOR COMMUNITY MENTAL HEALTH SUPPORTS (HCBS-CMHS)
8.509.10 GENERAL PROVISIONS 8.509.11 LEGAL BASIS
A. The Home and Community Based Services for COMMUNITY MENTAL HEALTH SUPPORTS (HCBS-CMHS) program in Colorado is authorized by a waiver of the amount, duration, and scope of services requirements contained in Section 1902(a)(10)(B) of the Social Security Act.
The waiver was granted by the United States Department of Health and Human Services, under Section 1915(c) of the Social Security Act. The HCBS-CMHS program is also authorized under state law at 25.5-6-601 through 25.5-6-607, C.R.S. (2012). The number of recipients served in the HCBS-CMHS program is limited to the number of recipients authorized in the waiver.
B. All congregate facilities where any HCBS client resides must be in compliance with the “Keys Amendment” as required under Section 1616(e) of the Social Security Act of 1935 and 45 CFR Part 1397 (October 1, 1991), by possession of a valid Assisted Living Residence license issued under 25-27-105, CR.S. (1999), and regulations of the Colorado Department of Public Health and Environment at 6 CCR 1011-1, Chapters 2 and 7.
Pursuant to 24-4-103(12.5), C.R.S., the Department of Health Care Policy and Financing maintains with electronic or written copies of the incorporated texts for public inspection. Copies may be obtained at a reasonable cost or examined during regular business hours at 1570 Grant Street, Denver, CO, 80203. Additionally, any incorporated material in these rules may be examined at any State depository library.
8.509.12 SERVICES PROVIDED [Eff. 7/1/2012] A. HCBS-CMHS services provided as an alternative to nursing facility placement include:
1. Adult Day Services
2. Alternative Care Facility Services (which includes Homemaker and Personal Care services)
3. Consumer Directed Attendant Support Services (CDASS)
4. Electronic Monitoring
5. Home Modification 6. Homemaker Services
7. Non-Medical Transportation
8. Personal Care
9. Respite Care
B. Case management is not a service of the HCBS-CMHS program, but shall be provided as an administrative activity through case management agencies.
C. HCBS-CMHS clients are eligible for all other Medicaid State plan benefits.
CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.500 Medical Services Board 114
8.509.13 DEFINITIONS OF SERVICES
A. Adult Day Services is defined at Section 8.491, ADULT DAY SERVICES.
B. Alternative Care Facility Services is defined at Section 8.495, ALTERNATIVE CARE FACILITY.
C. Consumer Directed Attendant Support Services (CDASS) is defined at Section 8.510, CONSUMER DIRECTED ATTENDANT SUPPORT SERVICES C.
Electronic Monitoring services is defined at Section 8.488, ELECTRONIC MONITORING.
D. Home Modification is defined at Section 8.493, HOME MODIFICATION.
E. Homemaker Services is defined at Section 8.490, HOMEMAKER SERVICES. F. Non-Medical Transportation is defined at Section 8.494, NON-MEDICAL TRANSPORTATION.
G. Personal Care is defined at Section 8.489, PERSONAL CARE.
H. Respite is defined at Section 8.492, RESPITE. 8.509.14
GENERAL DEFINITIONS
A. Assessment shall be defined as a client evaluation according to requirements at Section 8.509.31, (B).
B. Case Management shall be defined as administrative functions performed by a case management agency according to requirements at Section 8.509.30.
C. Case Management Agency shall be defined as an agency that is certified and has a valid contract with the state to provide HCBS-CMHS case management.
D. Case Plan shall be defined as a systematized arrangement of information which includes the client's needs; the HCBS-CMHS services and all other services which will be provided, including the funding source, frequency, amount and provider of each service; and the expected outcome or purpose of such services. This case plan shall be written on a state-prescribed case plan form.
E. Categorically Eligible, shall be defined in the HCBS-CMHS Program, as any person who is eligible for Medical Assistance (Medicaid), or for a combination of financial and Medical Assistance; and who retains eligibility for Medical Assistance even when the client is not a resident of a nursing facility or hospital, or a recipient of an HCBS program.
Categorically eligible shall not include persons who are eligible for financial assistance, or persons who are eligible for HCBS-CMHS as three hundred percent eligible persons, as defined at 8.509.14(S).
F. Congregate Facility shall be defined as a residential facility that provides room and board to three or more adults who are not related to the owner and who, because of impaired capacity for independent living, elect protective oversight, personal services and social care but do not require regular twenty-four hour medical or nursing care.
G. Uncertified Congregate Facility is a facility as defined in Section 8.509.14(F) that is not certified as an Alternative Care Facility, which is defined at Section 8.495.11.
H. Continued Stay Review shall be defined as a re-assessment as defined at Section 8.402.60.
I. Cost Containment shall be defined at Section 8.485.50(J) CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.500 Medical Services Board 115
J. Department shall be defined as the State Agency designated as the Single State Medicaid Agency for Colorado, or any division or sub-units within that agency, or another state agency operating under the authority of a memorandum of understanding with the Single State Medicaid Agency.
K. Deinstitutionalized shall be defined as waiver clients who were receiving nursing facility services reimbursed by Medicaid, within forty-five (45) calendar days of admission to HCBS-CMHS waiver.
These include hospitalized clients who were in a nursing facility immediately prior to inpatient hospitalization and who would have returned to the nursing facility if they had not elected the HCBS-CMHS waiver.
L. Diverted shall be define as HCBS-CMHS waiver recipients who were not deinstitutionalized, as defined at Section 8.485.50(K).
M. Home and Community Based Services for Community Mental Health Supports (HCBS-CMHS) shall be defined as services provided in a home or community based setting to clients who are eligible for Medicaid reimbursement for long term care, who would require nursing facility care without the provision of HCBS-CMHS, and for whom HCBS-CMHS services can be provided at no more than the cost of nursing facility care.
N. Intake/Screening/Referral shall be as defined at Section 8.390.1(J) and as the initial contact with clients by the case management agency. This shall include, but not be limited to, a preliminary screening in the following areas: an individual's need for long term care services; an individual's need for referral to other programs or services; an individual's eligibility for financial and program assistance; and the need for a comprehensive long term care client assessment.
O. Level Of Care Screen shall be described as an assessment in Section 8.401.
P. Non-Diversion shall be defined as a client who was certified by the Utilization Review Contractor (URC) as meeting the level of care screen and target group for the HCBS-CMHS program, but who did not receive HCBS-CMHS services for some other reason.
Q. Provider Agency shall be defined as an agency certified by the Department and which has a contract with the Department, in accordance with Section 8.487, HCBS-EBD PROVIDER AGENCIES, to provide one of the services listed at Section 8.509.13. A case management agency may also become a provider if the criteria at Sections 8393.6 and 8.487 are met.
R. Reassessment shall be defined as a periodic revaluation according to the requirements at Section 8.509.32. C.
S. Three Hundred Percent (300%) Eligible persons shall be defined as persons: 1) Whose income does not exceed 300% of the SSI benefit level, and 2) Who, except for the level of their income, would be eligible for an SSI payment; and 3) Who are not eligible for medical assistance (Medicaid) unless they are recipients in an HCBS program, or are in a nursing facility or hospitalized for thirty (30) consecutive days.
CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.500 Medical Services Board 116 8.509.15 ELIGIBLE PERSONS A. HCBS-CMHS services shall be offered to persons who meet all of the eligibility requirements below: 1. Financial Eligibility Clients shall meet the eligibility criteria as specified in the Income Maintenance Staff Manual of the Colorado Department of Human Services at 9 CCR 2503-1, and the Colorado Department of Health Care Policy and Finacning regulations at 10 CCR 2505- 10, Section 8.100, MEDICAL ASSISTANCE ELIGIBILITY. 2. Level of Care AND Target Group.
Clients who have been determined to meet the level of care AND target group criteria shall be certified by the Utilization Review Committee (URC) as functionally eligible for HCBS-CMHS. The URC shall only certify HCBS-CMHS eligibility for those clients: a. Determined to meet the target group definition, defined as a person experiencing a severe and persistent mental health need that requires assistance with one or more Activities of Daily Living (ADL); i. A person experiencing a severe and persistent mental health need is defined as someone who: 1) Is 18 years of age or older with a severe and persistent mental health need; and 2) Currently has or at any time during the past year leading up to assessment has a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within the Diagnostic and Statistical Manual of Mental Disorders (DSM -5); and a) Has a disorder that is episodic, recurrent, or has persistent features, but may vary in terms of severity and disabling effects; and b) Has resulted in functional impairment which substantially interferes with or limits one or more major life activities. ii. A severe and persistent mental health need does not include: 1) Intellectual or developmental disorders; or 2) Substance use disorder without a co-occurring diagnosis of a severe and persistent mental health need.
b. Determined by a formal level of care assessment to require the level of care available in a nursing facility, according to Section 8.401.11-15; and c. A length of stay shall be assigned by the URC for approved admissions, according to guidelines at Section 8.402.50. CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.500 Medical Services Board 117
3. Receiving Services
a. Only clients who receive HCBS-CMHS services, or who have agreed to accept HCBS-CMHS services as soon as all other eligibility criteria have been met, are eligible for the HCBS-CMHS program.
b. Case management is not a service and shall not be used to satisfy this requirement.
c. Desire or need for home health services or other Medicaid services that are not HCBS-CMHS services, as listed at Section 8.509.12, shall not satisfy this eligibility requirement. d. HCBS-CMHS clients who have not received HCBS-CMHS services for thirty (30) days shall be discontinued from the program.
4. Institutional Status a. Clients who are residents of nursing facilities or hospitals are not eligible for HCBS-CMHS services while residing in such institutions.
b. A client who is already an HCBS-CMHS recipient and who enters a hospital may not receive HCBS-CMHS services while in the hospital. If the hospitalization continues for 30 days or longer, the case manager must terminate the client from the HCBS-CMHS program.
c. A client who is already an HCBS-CMHS recipient and who enters a nursing facility may not receive HCBS-CMHS services while in the nursing facility;
1) The case manager must terminate the client from the HCBS-CMHS program if Medicaid pays for all or part of the nursing facility care, or if there is a URC-certified ULTC-100.2 for the nursing facility placement, as verified by telephoning the URC.
2) A client receiving HCBS-CMHS services who enters a nursing facility for Respite Care as a service under the HCBS-CMHS program shall not be required to obtain a nursing facility ULTC-100.2, and shall be continued as an HCBS-CMHS client in order to receive the HCBS-CMHS service of Respite Care in a nursing facility.
5. Cost-effectiveness Only clients who can be safely served within cost containment, as defined at Section 8.509.14 (I), are eligible for the HCBS-CMHS program. The equivalent cost of nursing facility care is calculated by the State, according to Section 8.509.19. 8.509.16 START DATE The start date of eligibility for HCBS-CMHS services shall not precede the date that all of the requirements at Section
8.509.15, have been met. The first date for which HCBS-CMHS services can be reimbursed shall be the LATER of any of the following: CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.500 Medical Services Board 118 A. Financial The financial eligibility start date shall be the effective date of eligibility, as determined by the income maintenance technician, according to Section 8.100. This may be verified by consulting the income maintenance technician, or by looking it up on the eligibility system. B. Level of Care This date is determined by the official URC stamp and the URC-assigned start date on the ULTC 100.2 form. C. Receiving Services This date shall be determined by the date on which the client signs either a case plan form, or a preliminary case plan (Intake) form, as prescribed by the state, agreeing to accept HCBS-CMHS services. D. Institutional Status HCBS-CMHS eligibility cannot precede the date of discharge from the hospital or nursing facility. 8.509.17 CLIENT PAYMENT OBLIGATION - POST ELIGIBILITY TREATMENT OF INCOME
8.509.10 GENERAL PROVISIONS 8.509.11 LEGAL BASIS
A. The Home and Community Based Services for COMMUNITY MENTAL HEALTH SUPPORTS (HCBS-CMHS) program in Colorado is authorized by a waiver of the amount, duration, and scope of services requirements contained in Section 1902(a)(10)(B) of the Social Security Act.
The waiver was granted by the United States Department of Health and Human Services, under Section 1915(c) of the Social Security Act. The HCBS-CMHS program is also authorized under state law at 25.5-6-601 through 25.5-6-607, C.R.S. (2012). The number of recipients served in the HCBS-CMHS program is limited to the number of recipients authorized in the waiver.
B. All congregate facilities where any HCBS client resides must be in compliance with the “Keys Amendment” as required under Section 1616(e) of the Social Security Act of 1935 and 45 CFR Part 1397 (October 1, 1991), by possession of a valid Assisted Living Residence license issued under 25-27-105, CR.S. (1999), and regulations of the Colorado Department of Public Health and Environment at 6 CCR 1011-1, Chapters 2 and 7.
Pursuant to 24-4-103(12.5), C.R.S., the Department of Health Care Policy and Financing maintains with electronic or written copies of the incorporated texts for public inspection. Copies may be obtained at a reasonable cost or examined during regular business hours at 1570 Grant Street, Denver, CO, 80203. Additionally, any incorporated material in these rules may be examined at any State depository library.
8.509.12 SERVICES PROVIDED [Eff. 7/1/2012] A. HCBS-CMHS services provided as an alternative to nursing facility placement include:
1. Adult Day Services
2. Alternative Care Facility Services (which includes Homemaker and Personal Care services)
3. Consumer Directed Attendant Support Services (CDASS)
4. Electronic Monitoring
5. Home Modification 6. Homemaker Services
7. Non-Medical Transportation
8. Personal Care
9. Respite Care
B. Case management is not a service of the HCBS-CMHS program, but shall be provided as an administrative activity through case management agencies.
C. HCBS-CMHS clients are eligible for all other Medicaid State plan benefits.
CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.500 Medical Services Board 114
8.509.13 DEFINITIONS OF SERVICES
A. Adult Day Services is defined at Section 8.491, ADULT DAY SERVICES.
B. Alternative Care Facility Services is defined at Section 8.495, ALTERNATIVE CARE FACILITY.
C. Consumer Directed Attendant Support Services (CDASS) is defined at Section 8.510, CONSUMER DIRECTED ATTENDANT SUPPORT SERVICES C.
Electronic Monitoring services is defined at Section 8.488, ELECTRONIC MONITORING.
D. Home Modification is defined at Section 8.493, HOME MODIFICATION.
E. Homemaker Services is defined at Section 8.490, HOMEMAKER SERVICES. F. Non-Medical Transportation is defined at Section 8.494, NON-MEDICAL TRANSPORTATION.
G. Personal Care is defined at Section 8.489, PERSONAL CARE.
H. Respite is defined at Section 8.492, RESPITE. 8.509.14
GENERAL DEFINITIONS
A. Assessment shall be defined as a client evaluation according to requirements at Section 8.509.31, (B).
B. Case Management shall be defined as administrative functions performed by a case management agency according to requirements at Section 8.509.30.
C. Case Management Agency shall be defined as an agency that is certified and has a valid contract with the state to provide HCBS-CMHS case management.
D. Case Plan shall be defined as a systematized arrangement of information which includes the client's needs; the HCBS-CMHS services and all other services which will be provided, including the funding source, frequency, amount and provider of each service; and the expected outcome or purpose of such services. This case plan shall be written on a state-prescribed case plan form.
E. Categorically Eligible, shall be defined in the HCBS-CMHS Program, as any person who is eligible for Medical Assistance (Medicaid), or for a combination of financial and Medical Assistance; and who retains eligibility for Medical Assistance even when the client is not a resident of a nursing facility or hospital, or a recipient of an HCBS program.
Categorically eligible shall not include persons who are eligible for financial assistance, or persons who are eligible for HCBS-CMHS as three hundred percent eligible persons, as defined at 8.509.14(S).
F. Congregate Facility shall be defined as a residential facility that provides room and board to three or more adults who are not related to the owner and who, because of impaired capacity for independent living, elect protective oversight, personal services and social care but do not require regular twenty-four hour medical or nursing care.
G. Uncertified Congregate Facility is a facility as defined in Section 8.509.14(F) that is not certified as an Alternative Care Facility, which is defined at Section 8.495.11.
H. Continued Stay Review shall be defined as a re-assessment as defined at Section 8.402.60.
I. Cost Containment shall be defined at Section 8.485.50(J) CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.500 Medical Services Board 115
J. Department shall be defined as the State Agency designated as the Single State Medicaid Agency for Colorado, or any division or sub-units within that agency, or another state agency operating under the authority of a memorandum of understanding with the Single State Medicaid Agency.
K. Deinstitutionalized shall be defined as waiver clients who were receiving nursing facility services reimbursed by Medicaid, within forty-five (45) calendar days of admission to HCBS-CMHS waiver.
These include hospitalized clients who were in a nursing facility immediately prior to inpatient hospitalization and who would have returned to the nursing facility if they had not elected the HCBS-CMHS waiver.
L. Diverted shall be define as HCBS-CMHS waiver recipients who were not deinstitutionalized, as defined at Section 8.485.50(K).
M. Home and Community Based Services for Community Mental Health Supports (HCBS-CMHS) shall be defined as services provided in a home or community based setting to clients who are eligible for Medicaid reimbursement for long term care, who would require nursing facility care without the provision of HCBS-CMHS, and for whom HCBS-CMHS services can be provided at no more than the cost of nursing facility care.
N. Intake/Screening/Referral shall be as defined at Section 8.390.1(J) and as the initial contact with clients by the case management agency. This shall include, but not be limited to, a preliminary screening in the following areas: an individual's need for long term care services; an individual's need for referral to other programs or services; an individual's eligibility for financial and program assistance; and the need for a comprehensive long term care client assessment.
O. Level Of Care Screen shall be described as an assessment in Section 8.401.
P. Non-Diversion shall be defined as a client who was certified by the Utilization Review Contractor (URC) as meeting the level of care screen and target group for the HCBS-CMHS program, but who did not receive HCBS-CMHS services for some other reason.
Q. Provider Agency shall be defined as an agency certified by the Department and which has a contract with the Department, in accordance with Section 8.487, HCBS-EBD PROVIDER AGENCIES, to provide one of the services listed at Section 8.509.13. A case management agency may also become a provider if the criteria at Sections 8393.6 and 8.487 are met.
R. Reassessment shall be defined as a periodic revaluation according to the requirements at Section 8.509.32. C.
S. Three Hundred Percent (300%) Eligible persons shall be defined as persons: 1) Whose income does not exceed 300% of the SSI benefit level, and 2) Who, except for the level of their income, would be eligible for an SSI payment; and 3) Who are not eligible for medical assistance (Medicaid) unless they are recipients in an HCBS program, or are in a nursing facility or hospitalized for thirty (30) consecutive days.
CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.500 Medical Services Board 116 8.509.15 ELIGIBLE PERSONS A. HCBS-CMHS services shall be offered to persons who meet all of the eligibility requirements below: 1. Financial Eligibility Clients shall meet the eligibility criteria as specified in the Income Maintenance Staff Manual of the Colorado Department of Human Services at 9 CCR 2503-1, and the Colorado Department of Health Care Policy and Finacning regulations at 10 CCR 2505- 10, Section 8.100, MEDICAL ASSISTANCE ELIGIBILITY. 2. Level of Care AND Target Group.
Clients who have been determined to meet the level of care AND target group criteria shall be certified by the Utilization Review Committee (URC) as functionally eligible for HCBS-CMHS. The URC shall only certify HCBS-CMHS eligibility for those clients: a. Determined to meet the target group definition, defined as a person experiencing a severe and persistent mental health need that requires assistance with one or more Activities of Daily Living (ADL); i. A person experiencing a severe and persistent mental health need is defined as someone who: 1) Is 18 years of age or older with a severe and persistent mental health need; and 2) Currently has or at any time during the past year leading up to assessment has a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within the Diagnostic and Statistical Manual of Mental Disorders (DSM -5); and a) Has a disorder that is episodic, recurrent, or has persistent features, but may vary in terms of severity and disabling effects; and b) Has resulted in functional impairment which substantially interferes with or limits one or more major life activities. ii. A severe and persistent mental health need does not include: 1) Intellectual or developmental disorders; or 2) Substance use disorder without a co-occurring diagnosis of a severe and persistent mental health need.
b. Determined by a formal level of care assessment to require the level of care available in a nursing facility, according to Section 8.401.11-15; and c. A length of stay shall be assigned by the URC for approved admissions, according to guidelines at Section 8.402.50. CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.500 Medical Services Board 117
3. Receiving Services
a. Only clients who receive HCBS-CMHS services, or who have agreed to accept HCBS-CMHS services as soon as all other eligibility criteria have been met, are eligible for the HCBS-CMHS program.
b. Case management is not a service and shall not be used to satisfy this requirement.
c. Desire or need for home health services or other Medicaid services that are not HCBS-CMHS services, as listed at Section 8.509.12, shall not satisfy this eligibility requirement. d. HCBS-CMHS clients who have not received HCBS-CMHS services for thirty (30) days shall be discontinued from the program.
4. Institutional Status a. Clients who are residents of nursing facilities or hospitals are not eligible for HCBS-CMHS services while residing in such institutions.
b. A client who is already an HCBS-CMHS recipient and who enters a hospital may not receive HCBS-CMHS services while in the hospital. If the hospitalization continues for 30 days or longer, the case manager must terminate the client from the HCBS-CMHS program.
c. A client who is already an HCBS-CMHS recipient and who enters a nursing facility may not receive HCBS-CMHS services while in the nursing facility;
1) The case manager must terminate the client from the HCBS-CMHS program if Medicaid pays for all or part of the nursing facility care, or if there is a URC-certified ULTC-100.2 for the nursing facility placement, as verified by telephoning the URC.
2) A client receiving HCBS-CMHS services who enters a nursing facility for Respite Care as a service under the HCBS-CMHS program shall not be required to obtain a nursing facility ULTC-100.2, and shall be continued as an HCBS-CMHS client in order to receive the HCBS-CMHS service of Respite Care in a nursing facility.
5. Cost-effectiveness Only clients who can be safely served within cost containment, as defined at Section 8.509.14 (I), are eligible for the HCBS-CMHS program. The equivalent cost of nursing facility care is calculated by the State, according to Section 8.509.19. 8.509.16 START DATE The start date of eligibility for HCBS-CMHS services shall not precede the date that all of the requirements at Section
8.509.15, have been met. The first date for which HCBS-CMHS services can be reimbursed shall be the LATER of any of the following: CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.500 Medical Services Board 118 A. Financial The financial eligibility start date shall be the effective date of eligibility, as determined by the income maintenance technician, according to Section 8.100. This may be verified by consulting the income maintenance technician, or by looking it up on the eligibility system. B. Level of Care This date is determined by the official URC stamp and the URC-assigned start date on the ULTC 100.2 form. C. Receiving Services This date shall be determined by the date on which the client signs either a case plan form, or a preliminary case plan (Intake) form, as prescribed by the state, agreeing to accept HCBS-CMHS services. D. Institutional Status HCBS-CMHS eligibility cannot precede the date of discharge from the hospital or nursing facility. 8.509.17 CLIENT PAYMENT OBLIGATION - POST ELIGIBILITY TREATMENT OF INCOME