10 Colo. Code Regs. § 2505-10-8.509
Current through Register Vol. 47, No. 16, August 25, 2024
Section 10 CCR 2505-10-8.509 - [Effective 9/14/2024] HOME AND COMMUNITY-BASED SERVICES FOR COMMUNITY MENTAL HEALTH SUPPORTS (HCBS-CMHS)8.509.17POST-ELIGIBILITY TREATMENT OF INCOME (PETI)A. Definition 1. Post Eligibility Treatment of Income (PETI) means the calculation used to determine the member's obligation (payment) for the payment of services.B. Post Eligibility Treatment of Income Application 1. When a member has been determined eligible for Home and Community-based Services (HCBS) under the 300% income standard, according to Section 8.100, the Department may reduce Medicaid payment for Alternative Care Facility (ACF) services according to the procedures for calculation of PETI at Section 8.509.31.2. PETI is required for Medicaid members residing in Alternative Care Facilities under the Home and Community Based Services (HCBS) Community Mental Health Support (CMHS) waiver. C. Case Management Responsibilities1. For 300% eligible members who are Alternative Care Facility (ACF) members, the case manager shall complete a State-prescribed form, which calculates the member payment according to the following procedures: a. The member's Total Gross Monthly Income is determined by adding the Gross Monthly Income to the Gross Monthly Long-Term Care (LTC) Insurance amount. The member's Room and Board amount shall be deducted from the gross income and paid to the provider.
b. The member's Personal Needs Allowance (PNA) amount is based upon a member's gross income, up to the maximum amount set by the Department. For a member with financial responsibility for only a spouse, the amount protected under Spousal Protection as defined in Section 8.100.7 K shall be deducted from the member's gross income.
If the member is financially responsible for a spouse plus other dependents, or with financial responsibility for other dependents only, an amount equal to the appropriate Temporary Assistance to Needy Families (TANF) grant level amount
c. less any income of the spouse and/or dependents (excluding income from part-time employment earnings of a dependent child, as defined at Section 8.100.1, who is either a full-time student or a part-time student) shall be deducted from the member's gross income. d. Amounts for incurred expenses for medical or remedial care for the member that are not covered by Medicare, Medicaid, or other third party shall be deducted from the member's gross income as follows: i. Health insurance premiums, deductibles or coinsurance charges if health insurance coverage is documented. ii. Necessary dental care not to exceed amounts equal to actual expenses incurred. iii. Vision and auditory care expenses not to exceed amounts equal to actual expenses incurred. iv. Medications, with the following limitations: a) The member has a prescription for the medication. b) Medications which may be purchased through regular Medicaid prior authorization procedures shall not be allowed. c) The full cost of brand-name medications shall not be allowed if a generic form is available at a lower price, unless the prescriber has specifically prescribed a name brand medication over the generic formula. e. Other necessary medical or remedial care or items shall be deducted from the member's gross income, with the following limitations: i. The need for such care must be documented in writing by the attending physician. The documentation shall list the service, supply, or equipment; state why it is medically necessary; be signed by the physician; and shall be renewed at least annually or whenever there is a change. ii. Any service, supply or equipment that is available under State Plan Medicaid, with or without prior authorization, shall not be allowed as a deduction. f. Deductions for medical and remedial care may be allowed up to the end of the next full month while the physician's prescription is being obtained. If the physician's prescription cannot be obtained by the end of the next full month, the deduction shall be discontinued. If the case manager cannot immediately determine whether a particular medical or remedial service, supply, equipment, or medication is a benefit of Medicaid, the deduction may be allowed up to the end of the next full month while the case manager determines whether such deduction is a benefit of the Medicaid program. If it is determined that the service, supply, equipment, or medication is a benefit of Medicaid, the deduction shall be discontinued.
g. Verifiable Federal and State tax liabilities shall be an allowable deduction up to $300 per month from the member's gross income. h. Any remaining income shall be applied to the cost of the ACF services, as defined at Section 8.509.31.E, and shall be paid by the member directly to the provider. i. If there is still income remaining after the entire cost of ACF services are paid from the member's income, the remaining income shall be kept by the member and may be used at the member's discretion. 2. Case managers shall inform HCBS ACF services members of their payment obligations in a manner prescribed by the Department at the beginning of each support plan year and whenever there is a significant change to their payment obligation. a. Significant change is defined as fifty dollars ($50) or more. 3. Copies of member payment forms shall be kept in the member files at the case management agency. A copy of the form may be requested by the Department for monitoring purposes.8.509.18STATE PRIOR AUTHORIZATION OF SERVICESA. Upon receipt of the Prior Authorization Request (PAR), as described at Section 8.509.31, the state or its agent shall review the PAR to determine whether it is in compliance with all applicable regulations, and whether services requested are consistent with the Client's documented medical condition and functional capacity, and are reasonable in amount, frequency, and duration. Within ten (10) working days the State or its agent shall: 1.Approve the PAR and forward signed copies of the prior authorization form to the case management agency, when all requirements are met;2.Return the PAR to the case management agency, whenever the PAR is incomplete, illegible, unclear, or incorrect; or if services requested are not adequately justified;3.Disapprove the PAR when all requirements are not met Services shall be disapproved that are duplicative of other services that the Client is receiving or services for which the Client is receiving funds to purchase Services shall also be disapproved if all services, regardless of funding source, total more than twenty-four hours per day care.B. When services are disapproved, in whole or in part the Department or its agent shall notify the case management agency. The case management agency shall notify the Client of the adverse action and the appeal rights on a state-prescribed form, according to Section 8.057, et seq.C. Revisions received by the Department or its agent six (6) months or more after the end date shall always be disapproved.D. Approval of the PAR by the Department or its agent shall authorize providers of services under the case plan to submit claims to the fiscal agent and to receive payment for authorized services provided during the period of time covered by the PAR. Payment is also conditional upon the Client's financial eligibility for long-term care medical assistance (Medicaid) on the dates of service; and upon providers' use of correct billing procedures.8.509.20CASE MANAGEMENT AGENCIESA. The requirement at Section 8.390 et. seq. shall apply to the case management agencies performing the case management functions of the HCBS-CMHS program.8.509.50MENTAL HEALTH TRANSITIONAL LIVING HOMESA. Definitions 1. Activities of daily living (ADLs) means basic self-care activities including bathing, bowel and bladder control, dressing, eating, independent ambulation, and supervision to support behavior, medical needs and memory/cognition.2. Authorized Representative means an individual designated by a member, or by the parent or guardian of the member receiving services, if appropriate, to assist the member receiving services 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) or In-Home Support Services (IHSS).3. Case Management Agency means a public, private, or non-governmental non-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 that has signed a provider participation agreement with the state department.4. Department means the Department of Health Care Policy and Financing, the Single State Medicaid Agency.5. Incident means an actual or alleged event that creates the risk of serious harm to the health or welfare of an individual receiving services; or it may endanger or negatively impact the mental and/or physical well-being of an individual. Critical Incidents include, but are not limited to, injury/illness; abuse/neglect/exploitation; damage/theft of property; medication mismanagement; lost or missing person; criminal activity; unsafe housing/displacement; or death.6. Medication Administration as described in 25-1.5-301, C.R.S., means assisting a member with taking medications while using standard healthcare precautions, according to the legibly written or printed order of an attending physician or other authorized practitioner. Medication administration may include assistance with ingestion, application, inhalation, and rectal or vaginal insertion of medication, including prescription drugs. "Administration" does not include judgment, evaluation, assessment, or the injections of medication, the monitoring of medication, or the self-administration of medication, including prescription drugs and including the self-injection of medication by the member.7. Mental Health Transitional Living Home (MHTL) Certification means documentation from the Colorado Department of Public Health and Environment (CDPHE) recommending certification to the Department after the provider has met all licensing and regulatory requirements.8. Protective Oversight means monitoring and guidance of a member to assure their health, safety, and well-being. Protective oversight includes but is not limited to: monitoring the member while on the premises, monitoring ingestion and reactions to prescribed medications, if appropriate, reminding the member to carry out activities of daily living, and facilitating medical and other health appointments.9. Person-Centered Support Plan means a service and support plan that is directed by the member whenever possible, with the member's representative acting in a participatory role as needed, is prepared by the case manager under Sections 8.393.2.E or 8.519.11, identifies the supports needed for the individual to achieve personally identified goals, and is based on respecting and valuing individual preferences, strengths, and contributions.10. Provider means the entity that is enrolled with the Department and holds the Assisted Living Residence license and MHTL certification.B. Member Eligibility 1. MHTL services are available to members who meet the following requirements: a. Members are enrolled in the HCBS-CMHS waiver; andb. Members require the specialized services provided under the MHTL as determined by assessed need.C. Member Benefits 1. The MHTL service will assist the member to reside in the most integrated setting appropriate to their needs. Staff will be specifically trained to support members with a severe and persistent mental illness and who may be experiencing a mental health crisis or episode.2. This residential service will include the following: a. Protective oversight and supervision;b. Assistance with administering medication and medication management;c. Assistance with community participation and support in accessing the community; d. Assistance with recreational and social activities;e. Housing planning and navigation services as appropriate for members experiencing homelessness/at risk for homelessness;f. Life skills training; andg. ADL support as needed.3. Room and board is not a benefit of MHTL services. Members are responsible for room and board in an amount not to exceed the Department's established rate.4. Additional services that are available as a State Plan benefit or other HCBS-CMHS waiver service are not a MHTL benefit. 5. Member engagement opportunities shall be provided by the MHTL home, as outlined in 6 CCR 1011-1, Chapter VII, Section 12.19-26.D. Member Rights 1. Members shall be informed of their rights, according to 6 CCR 1011-1, Chapter VII, Section 13 and 10 CCR 2505-108.484. Any modification of those rights shall be in accordance with Section 8.484.5. Pursuant to 6 CCR 1011-1, Chapter VII, Section 13.1, the policy on resident rights shall be in a visible location so that they are always available to members and visitors.2. Members shall be informed of all policies specific to the MHTL setting upon admission to the setting, and when changes to policies are made, rules and/or policies shall apply consistently to the administrator, staff, volunteers, and members residing in the facility and their family or friends who visit. Member acknowledgement of rules and policies must be documented in the support plan or a resident agreement.3. If requested by the member, the MHTL home shall provide bedroom furnishings, including but not limited to a bed, bed and bath linens, a lamp, chair and dresser and a way to secure personal possessions.E. Provider Eligibility 1. To be certified as an MHTL provider, the entity seeking certification must be licensed by CDPHE as an Assisted Living Residence (ALR) pursuant to 6 CCR 1011-1, Ch. VII.2. Applicants for MHTL Certification shall meet the applicable standards of the rules for building, fire, and life safety code enforcement as adopted by the Colorado Division of Fire Prevention and Control (DFPC).3. MHTL providers must receive a recommendation for MHTL Certification. CDPHE issues a recommendation for MHTL Certification to the Department when the provider is in full compliance with the requirements set forth in these regulations. 4. No recommendation for MHTL Certification shall be issued if the owner, applicant, or administrator of the MHTL has been convicted of a felony or misdemeanor involving a crime of moral turpitude or that involves conduct that the Department determines could pose a risk to the health, safety, or welfare of the members residing in the MHTL setting.5. All MHTL homes are operated or contracted by the Department of Human Services or Behavioral Health Administration.F. Provider Roles and Responsibilities 1. Service Requirements a. The facility shall provide Protective Oversight and MHTL services to members every day of the year, 24 hours per day.b. MHTL providers shall maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII and XXIV, Medication Administration Regulations.c. MHTL providers shall not discontinue services to a member unless documented efforts have been ineffective to resolve the conflict leading to the discontinuance of services in accordance with 6 CCR 1011-1, Ch. VII Section 11.d. Providers shall maintain the following records/files: i. Personnel files for all staff and volunteers shall include: 1) Name, home address, phone number and date of hire.2) Job description, chain of supervision and performance evaluation(s).3) Trainings completed by the staff member and date of completion.ii. Member files shall be kept confidential and shall include: 1) The member's intake assessment, support plan and signed resident agreement.2) Providers must document and keep a record of each medication administered, including the time and the amount taken.e. The provider shall encourage and assist members' participation in engagement opportunities and activities within the MHTL home community and the wider community, when appropriate.f. The provider shall develop emergency policies that address, at a minimum, a plan that ensures the availability of, or access to, emergency power for essential functions and all member-required medical devices or auxiliary aids.2. Person Centered Support Plan a. The support plan must outline the goals, choices, preferences, and needs of the member. Medical information must also be included, specifically: i. If the member is taking any medications and how they are administered, with reference to the Medication Administration Record (MAR);ii. Supports needed with ADLs;iii. Special dietary needs, if any; andiv. Reference to any documented physician orders.b. The support plan must contain evidence that the member and/or their guardian, designated representative, or legal representative has had the opportunity to participate in the development of the support plan, has reviewed it, and has signed in agreement with the plan.3. Incident Reporting a. An Incident means an actual or alleged event that creates the risk of serious harm to the health or welfare of a member. An incident may endanger or negatively impact the mental and/or physical well-being of a member.b. Case management agencies and providers shall have a written policy and procedure for the timely reporting, recording and reviewing of incidents which shall include, but not be limited to: i. Death of member receiving services; ii. Hospitalization of member receiving services;iii. Medical emergencies, above and beyond first aid, involving member receiving services;iv. Allegations of abuse, neglect, exploitation, or mistreatment;v. Injury to member or illness of member; vi. Damage or theft of member's personal property;vii. Errors in medication administration;viii. Lost or missing person receiving services;x. Incidents or reports of actions by member receiving services that are unusual and require review; andxi. Use of a rights modification.c. A provider must submit a verbal or written report of every incident to the HCBS member's Case Management Agency (CMA) case manager within 24 hours of discovery of the actual or alleged incident. The report must include: i. Name of person reporting;ii. Name of member who was involved in the incident;iii. Member's Medicaid identification number; iv. Name of persons involved or witnessing the incident;vi. Date, time, and duration of incident;vii. Location of incident;ix. Description of incident;x. Description of action taken;xi. Whether the incident was observed directly or reported to the provider;xii. Name of person notified;xiii. Follow-up action taken or where to find documentation of further follow-up;xiv. Name of the person responsible for follow up; andxv. Resolution, if applicable.a. If any of the above information is not available within 24 hours of the incident and not reported to the CMA case manager, a follow-up to the initial report must be completed.b. Additional follow up information may also be requested by the case manager, or the Department. A provider agency is required to submit all follow up information within the timeframe specified by the requesting entity.c. Case management agencies and providers shall review and analyze information from incident reports to identify trends and problematic practices which may be occurring in specific services and shall take appropriate corrective action to address problematic practices identified.4. Staffing a. The MHTL home must have appropriate staffing levels to meet the individual acuity, needs and level of assistance required of the members in the setting.b. In addition to the trainings outlined in 6 CCR 1011-1, Ch. VII, Section 7, staff must be trained in the following topics prior to working independently with members: i. Mental Health First Aid.ii. Question, Persuade, Refer (QPR).iii. Suicide and Homicide Risk Screenings.iv. Trauma Informed Care Methodologies and Techniques.vii. Motivational Interviewing.viii. Transitional Planning.ix. Community Reinforcement and Family Training.G. Reimbursement 1. MHTL services are reimbursed on a per diem basis, as determined by the Department. Providers must be certified and enrolled with the Department prior to rendering services.2. Additional Charges a. Providers shall not bill supplemental charges to any members, except for amounts designated as copayments by the Department. i. Federal regulations require that Medicaid providers accept Medicaid reimbursements as payment in full (42 C.F.R. § 447.15). Section 25.5-4-301(1), C.R.S., prohibits providers from charging members or their responsible parties for Medicaid services covered under Title XIX of the Social Security Act.ii. HCBS members are not liable for the cost or additional cost of any waiver serviceiii. Disallowed supplemental charges include, but are not limited to, any fees such as enrollment fees or one-time fees, annual or monthly fees, registration fees, program placement hold fees, fees for supplies, basic utilities.46 CR 13, July 10, 2023, effective 7/30/202346 CR 17, September 10, 2023, effective 9/30/202346 CR 21, November 10, 2023, effective 11/30/202347 CR 16, August 25, 2024, effective 9/14/2024