10 Colo. Code Regs. § 2505-10-8.415
Current through Register Vol. 47, No. 24, December 25, 2024
Section 10 CCR 2505-10-8.415 - ROLE OF COUNTIES AND NURSING FACILITIES.10ROLE OF THE COUNTY DEPARTMENT OF SOCIAL/HUMAN SERVICE STAFF IN NURSING FACILITY PLACEMENTSThe County Department of Social/Human Services shall be responsible for the following in all nursing facility placements involving either clients of medical assistance or applicants for assistance:
A. The determination of existing or potential eligibility for medical assistance.B. The referral, whenever possible, of all Medicaid eligible clients/applicants who are eligible for Medicare benefits to facilities certified for participation in the Medicare Program.C. In those instances in which an individual residing in a nursing facility under some method of reimbursement other than Medicaid makes application for medical assistance, the county must provide notice of the application referral date to both the nursing facility and the Utilization Review Contractor.1. Such notice must be provided verbally to both the facility and the Utilization Review Contractor within two (2) working days of the application referral date.2. Written notice must be mailed to the facility within five (5) working days.3. Such notice is critical to the timely conduct of admission review by the Utilization Review Contractor.D. In those instances where eligibility is determined to be effective three months prior to the date of application pursuant to Department rules and regulations, the County Department of Social/Human Services shall notify the nursing facility of this circumstance in writing. This should be written in the area reserved for comments in Section VI(5) of the Form AP-5615. Similar verbal or written notice must be given or mailed to the Utilization Review Contractor, utilizing a format as determined by the Department.
.11 The Form AP-5615 is intended as a method for communicating the status of a resident or applicant, or actions which change that status, between nursing facility, the County Department of Social/Human Services, and the Department. Examples of such actions are admission, discharge, readmission, death or changes in resident income. Failure to complete the AP-5615, or to properly verify information reported thereon in a timely fashion, results in inappropriate reimbursement to nursing facilities, inequitable assistance payments, and the loss of documentation necessary for Department field audit staff. Upon receipt of Form AP-5615, the County Department of Social/Human Services shall be responsible for the following. A. Verify, correct, and complete, when necessary, the client/applicant's name, State ID number, and all other identifying data:B. Verify client/applicant income. Such verification must occur on a regular basis. All income of the client which is in excess of the amount reserved for personal needs allowance, less earned income (if appropriate), less spousal and dependent care allowance, and less home maintenance allowance, and any other applicable changes to patient payment per Sections 8.100.5.E. through 8.100.7.V., must be applied by the client/applicant toward their care or retained within an income trust as required under applicable regulations. Changes in income must be reflected in submission of a new eligibility reporting form and a new AP-5615.C. Calculation of Patient Payment. Other medical and remedial expenses covered under the nursing facility PETI must be preapproved by the Department. Nursing facility PETI-approved expenses are allowed only for residents with a patient payment but do not change the patient payment amount. For nursing facility PETI, see Sections 8.482.33 and 8.100.7.V.3.) The Department may make an exception for: 1. Hospice related PETI-IME adjustments.2. Resolution of appeals related to patient liability or PETI-IME adjustments.D. Verify client payment. This amount must be calculated by per diem appropriately in all months for which Medicaid reimbursement covers less than a full month's care. 1. Client payment may be waived and zero (-0-) client payment applied only under the conditions as defined in Section 8.482.34.D.1.2. Client payment may not be waived (other than for the exceptions provided for in Section 8.415.11.C.1), in the instances defined in Section 8.482.34.D.2.3. When client payment is calculated by per diem, the amount shown on the AP-5615 will be that amount to be paid by the resident, rather than the amount to be calculated by per diem calculation.4. Corrections to income or client payment shall be initialed and dated by the income maintenance technician from the County Department of Social/Human Services.E. Review the date of action, such as admission, readmission, discharge, death, or change in client payment being reported and verify as necessary;F. Indicate approval or denial of action being reported and effective date of that approval or denial; andG. Sign and date all copies. Provide a copy to the facility and the Department at HCPF_LTC_FinCompliance@state.co.us. 8.415.20 RESPONSIBILITY OF THE NURSING FACILITY IN NURSING FACILITY PLACEMENTSThese rules set forth the administrative procedures that must be followed by nursing facilities. Failure of the facility to meet the requirements set forth herein will result in denial of reimbursement.
A. Admission When an admission to the nursing facility is proposed, it is the responsibility of the nursing facility to:
1. Determine, prior to an applicant's admission, whether or not the individual is a member or has applied for medical assistance;2. Complete the ULTC 100.2 prior to or on the day of admission. Based on this information, the Utilization Review Contractor will determine the level of care and assign an initial length-of-stay.3. For purposes of this regulation, admission is defined as b. any change from other sources of reimbursement to the Medical Assistance program.B. Changes in Resident Status Form AP-5615 shall be used by the nursing facility to notify the County Department of the current or changed status of all members and applicants residing within the nursing facility.
1. The nursing facility shall initiate Form AP-5615 for all admissions, readmissions, transfers from private pay or Medicare, discharges, deaths, changes in resident income, and leaves of absence; and shall submit copies to the responsible county and the Department at HCPF_LTC_FinCompliance@state.co.us.2. The nursing facility is solely responsible for collecting the correct amount of client payment due from the resident, the family, or representatives. Failure to collect client pay, in whole or in part, shall not allow the nursing facility to bill the Medical Assistance Program for the uncollected client payment.3. The county department may initiate the AP-5615 when appropriate, which may include, but is not limited to, changes in resident income of which the county becomes aware.C. Transfer and Discharge The nursing facility must determine that all requirements for an orderly transfer or discharge are met before relinquishing their responsibility to the resident. This is necessary in order to assure continuity of total care. Therefore, the nursing facility is responsible for following the procedures as outlined at section C.R.S. section 25-1-120 et. seq, entitled "Nursing and intermediate care facilities- rights of patients", including the section on grievance procedures.
47 CR 01, January 10, 2024, effective 1/30/2024