10 Colo. Code Regs. § 2505-10-8.405

Current through Register Vol. 47, No. 24, December 25, 2024

Section 10 CCR 2505-10-8.405 - ADMISSION PROCEDURES: PROGRAMS FOR THE DEVELOPMENTALLY DISABLED

.10 PREADMISSION REVIEW

For admission to ICF/IID facilities clients must be evaluated by the Case Management Agency in the area where the client resides. If services will be provided through an agency in another area, the client shall be evaluated by that area's Case Management Agency.

The client shall be referred by the Case Management Agency to the URC for admission review and to the appropriate County Department of Social/Human Services for determination of Medicaid eligibility. The URC shall not determine admission certification under Medicaid for any intellectually or developmentally disabled client in the absence of a referral from the Case Management Agency except for emergency admissions to the Class I facilities.

.11 The Case Management Agency evaluation must contain background information as well as currently valid assessments of functional, developmental, behavioral, social, health, and nutritional status to determine if the facility can provide for the client's needs and if the client is likely to benefit from placement in the facility.

.12 Case Management Agency Adverse Recommendation

In cases where the Case Management Agency declines to recommend placement of a client into an ICF/IID facility, the Case Management Agency shall inform the client of the recommendation using the HCBS-DD-21 form. The Case Management Agency shall also notify the client or the client's designated representative of the client's right to request a formal URC level of care review.

The client shall have thirty (30) days from the postmark date of the notice to request a formal URC review. If the client requests a formal URC level of care review, the Case Management Agency shall submit the required documentation plus any new documentation submitted by the client to the URC. The URC shall review and make a level of care determination in accordance with the admission procedures below.

8.405.2ADMISSION PROCEDURES FOR ICF/IID FACILITIES

.21 When, based on Case Management Agency review, the Member cannot reasonably be expected to make use of ICF/IID or HCBS-DD, the Case Management Agency shall notify the physician and the URC. The physician and the URC/ Case Management Agency shall then proceed with the SNF or ICF placement under the provisions set forth at Section 8.402.10.

.22 When the Case Management Agency determines that a client is not appropriately served through HCBS-DD services or, in accordance with provisions permitting the client or the client's designated representative to choose institutional services as an alternative to HCBS-DD services, the Case Management Agency shall recommend placement to an ICF/IID facility. The Case Management Agency shall seek the approval of the client's physician. The physician shall notify the URC/ Case Management Agency agency of the proposed placement. Based on information provided by the Case Management Agency and the client's physician, the URC Case Management Agency may certify the client for long-term care prior to ICF/IID admission.

.23 The URC/ Case Management Agency shall advise the County Department of Social/Human Services of the certification to enable the County Department staff to assist with the placement arrangements.

.24. The LOC Screen and other transfer documents concerning medical information as applicable must accompany the client to the facility.

.25 Following receipt of the fully completed LOC Screen, the URC/ Case Management Agency shall review the information and make a final certification decision. If certification is approved, the URC/ Case Management Agency shall assign an initial length of stay according to Section 8.404.1. If certification is denied, the decision of the URC/CCB may be appealed in accordance with the appeals process at Section 8.057.

8.405.30ADMISSION PROCEDURES FOR HCBS-DD

.31 Case Management Agencies shall use evaluation and admission criteria at Sections 8.7100-8.7200 et seq.for HCBS-DD admissions Case Management Agencies may evaluate clients for HCBS-DD services if such services represent a viable alternative to SNF, ICF, or ICF/IID services. The evaluation shall be carried out in accordance with the procedures set forth in 2 C.C.R. Section 503-1.

.32 If the Case Management Agency recommends HCBS-DD placement, then the URC shall approve certification for services for the developmentally disabled at the level of care recommended by the Case Management Agency. The Member shall be placed in alternative service.

Following receipt of the completed LOC Screen and any other supporting information, the URC Case Management Agency shall review the information and make a final certification determination.

If certification is approved, the URC Case Management Agency shall assign an initial length of stay for HCBS-DD services.

If certification is denied, the decision of the URC/Case Management Agency may be appealed in accordance with Section 8.057.

8.405.4CONTINUED STAY REVIEW PROCEDURES; SERVICES FOR INDIVIDUALS WITH INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

.41 Continued Stay Reviews shall be conducted by the URC for all intellectually and clients in ICF/IID services, in accordance with 42 CFR Part 456 Subpart F.

.42 As a result of the Continued Stay Review, the URC shall renew or deny certification.

8.405.50GENERAL PROVISIONS

A. These rules shall not be construed nor interpreted to expand, diminish, or change any statutory provisions or duties of registered professional nurses, licensed practical nurses, or any other person subject to, or under the supervision of registered professional nurses or licensed practical nurses pursuant to the Professional Nurses Act, but are intended to explain the method by which the department shall reimburse the providers of nursing care services available under the Colorado Medical Assistance Program.

B. The Department of Health Care Policy and Financing ("Department") is the single state agency responsible for administration of the Medical Assistance Program ("Medicaid") pursuant to Title XIX of the Social Security Act. The Department is responsible for determining eligibility for program benefits; providers of medical care; level of reimbursement for the provision of medical care; and terms and conditions that shall govern the payment of such providers for the medical care services provided.

C. The Department receives partial reimbursement from federal funds pursuant to Titles I, X, XIV, XVI, and XIX of the Social Security Act.

D. All participating skilled nursing care facilities and intermediate health care facilities must be administered by a nursing facility administrator licensed pursuant to C.R.S. section 12-39-101 et seq. For inclusion in the audited cost rate (see 10 CCR 2505-10 section 8.440 et seq.) the administrator must be employed full-time by the applicant facility, and may not have other conflicting employment obligations. The administrator must be responsible on a 24-hour-a-day basis, with primary duties being performed during the day shift.

10 CCR 2505-10-8.405

46 CR 13, July 10, 2023, effective 7/30/2023

47 CR 16, August 25, 2024, effective 9/14/2024

47 CR 23, December 10, 2024, effective 12/30/2024