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 until 9/14/2024] HOME AND COMMUNITY-BASED SERVICES FOR COMMUNITY MENTAL HEALTH SUPPORTS (HCBS-CMHS)

8.509.10GENERAL PROVISIONS

8.509.11LEGAL 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 Sections 25.5-6-601 through 25.5-6-607, C.R.S. 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 possession of a valid Assisted Living Residence license issued under Section 25-27-105, C.R.S., and regulations of the Colorado Department of Public Health and Environment at 6 CCR 1011-1, Chapters 2 and 7.

8.509.12SERVICES 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 Services (which includes Homemaker and Personal Care services)

3. Consumer Directed Attendant Support Services (CDASS)

4. Electronic Monitoring

5. Home Delivered Meals

6. Home Modification

7. Homemaker Services

8. Life Skills Training (LST)

9. Non-Medical Transportation

10. Peer Mentorship

11. Personal Care

12. Respite Care

13. Transition Setup

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.

8.509.13DEFINITIONS OF SERVICES

A.Adult Day Services is defined at Section 8.491.

B.Alternative Care Services is defined at Section 8.495.1.

C. Consumer Directed Attendant Support Services (CDASS) is defined at Section 8.510.1.

D.Electronic Monitoring services is defined at Section 8.488.11.

E.Home Delivered Meals is defined at Section 8.553.1.

F.Home Modification is defined at Section 8.493.1.

G.Homemaker Services is defined at Section 8.490.1.

H.Life Skills Training (LST) is defined at Section 8.553.1.

I.Non-Medical Transportation is defined at Section 8.494.1.

J.Peer Mentorship is defined at Section 8.553.

K.Personal Care is defined at Section 8.500.94.B.12.

L.Respite is defined at Section 8.492.

M.Transition Setup is defined at Section 8.553.

8.509.14GENERAL DEFINITIONS

A.Assessment shall be defined as a Client evaluation according to requirements at Section 8.390.1 DEFINITIONS.

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.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.

E.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.

F.Uncertified Congregate Facility is a facility as defined in Section 8.509.14.G that is not certified as an Alternative Care Facility, which is defined at Section 8.495.1.

G.Continued Stay Review shall be defined as a Reassessment as defined in Section 8.390.1 and conducted as described at Section 8.402.60.

H.Cost Containment shall be defined at Section 8.485.50(I)

I.Department shall be defined as the State Agency designated as the Single State Medicaid Agency for Colorado, or another state agency operating under the authority of a memorandum of understanding with the Single State Medicaid Agency.

J.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.

K.Diverted shall be define as HCBS-CMHS waiver recipients who were not deinstitutionalized, as defined at Section 8.485.50(K).

L.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.

M.Intake/Screening/Referral shall be as defined at Section 8.390.1 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.

N.Level Ff Care Screen shall be defined as an assessment conducted in accordance with Section 8.401.16

O.Non-Diversion shall be defined as a Client who was certified by the 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.

P.Person-Centered Support Plan shall be as defined in Section 8.390.1 DEFINITIONS.

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 8.390-8.393 and 8.487 are met.

R.Reassessment shall be as defined in Section 8.390.1 DEFINITIONS.

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.

8.509.15ELIGIBLE 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 9 CCR 2503-5, and the Section 8.100.

2. Level of Care AND Target Group.

Clients who have been determined to meet the level of care AND target group criteria shall be determined by the Utilization Review Contractor (URC) as meeting the level of care eligibility for HCBS-CMHS. The URC shall only determine 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 LOC Screen 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.

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 LOC Eligibility Determination 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 LOC Screen and shall be continued as an HCBS-CMHS Client in order to receive the HCBS-CMHS service of Respite Care in a nursing facility.

8.509.16START 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:

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-assigned start date on the LOC Eligibility Determination.

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.

8.509.17POST-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 Responsibilities

1. 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 SERVICES

A. 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.

8.509.19STATE CALCULATION OF COST-CONTAINMENT AMOUNT

A. The State shall annually compute the equivalent monthly cost of nursing facility care according to Section 8.485.100.

B. LIMITATIONS ON PAYMENT TO FAMILY

1. With the exception of Consumer Directed Attendant Support Service, in no case shall any person be reimbursed to provide HCBS-CMHS services to his or her spouse.

2. Family members other than spouses may be employed by certified personal care agencies to provide personal care services to relatives under the HCBS-CMHS program subject to the conditions below. For purposes of this section, family shall be defined as all persons related to the Client by virtue of blood, marriage, adoption or common law.

3. The family member shall meet all requirements for employment by a certified personal care agency, and shall be employed and supervised by the personal care agency.

4. The family member providing personal care shall be reimbursed, using an hourly rate, by the personal care agency which employs the family member, with the following restrictions:

a. The maximum number of personal care units per annual certification for HCBS-CMHS shall be the equivalent of 444 hours. Family members must average at least 1.2164 hours of care per day (as indicated on the Client's care plan) in order to receive the maximum reimbursement.

b. The maximum shall include any portions of the Medicaid reimbursement which are kept by the personal care agency for unemployment insurance, worker's compensation, FICA, cost of training and supervision and all other administrative costs.

c. If the certification period for HCBS-CMHS is less than one year, the maximum reimbursement for relative personal care shall be calculated by multiplying the number of days the Client is receiving care by the average units per day for a full year (444/365=1.2164).

5. If two or more HCBS-CMHS Clients reside in the same household, family members may be reimbursed up to the maximum for each Client if the services are not duplicative and are appropriate to meet the Client's needs.

6. When HCBS-CMHS funds are utilized for reimbursement of personal care services provided by the Client's family, the home care allowance cannot be used to reimburse the family.

7. Services other than personal care or Consumer Directed Attendant Support Services shall not be reimbursed with the HCBS-CMHS funds when provided by the Client's family.

C. CLIENT RIGHTS

1. The case manager shall inform Clients eligible for HCBS-CMHS in writing, of their right to choose between HCBS-CMHS services and nursing facility care; and

2. The case manager shall offer Clients eligible for HCBS-CMHS, the free choice of any and all available and qualified providers of appropriate services.

8.509.20CASE MANAGEMENT AGENCIES

A. 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.

8.509.21 CERTIFICATION

A. Case management agencies shall be certified, monitored and periodically recertified as required in Section 8.394 et. seq.

B. Case management agencies must have provider agreements with the Department that are specific to the HCBS-CMHS program.

8.509.22 REIMBURSEMENT

Case management agencies shall be reimbursed for case management activities according to Section 8.392 et. seq.

8.509.30CASE MANAGEMENT FUNCTIONS

8.509.31 NEW HCBS-CMHS CLIENTS

A. INTAKE/SCREENING/REFERRAL

1. Case management agency staff shall complete a State-prescribed Intake form in accordance with the Single Entry Point Intake Procedures at Section 8.393.2 for each potential HCBS-CMHS Applicant. The Intake form must be completed before an assessment is initiated. The Intake form may also be used as a preliminary case plan form when signed by the Applicant for purposes of establishing a start date. Additionally, at intake, Clients shall be offered an opportunity to identify a third party to receive Client notices. This information shall be included on the intake form. This designee shall be sent copies of all notices sent to Clients.

2. Case management agency staff shall verify the individual's current financial eligibility status or refer the Client to the county department of social services of the Client's county of residence for application. This verification shall include whether the Applicant is in a category of assistance that includes financial eligibility for long-term care.

3. Based upon information gathered on the Intake form, the case manager shall determine the appropriateness of a referral for a Level of Care Eligibility Determination Screen and shall explain the reasons for the decision on the Intake form. The Client shall be informed of the right to request an LOC Screen if the Client disagrees with the case manager's decision.

4. If the case management agency staff has determined that a LOC Screen is needed, or if the Client requests one a case manager shall be assigned to schedule the assessment.

B. ASSESSMENT

1. The SEP case manager shall complete the LOC Screen in accordance with Section. C-D

2. The URC/SEP case manager shall begin and complete the LOC Screen within ten (10) days of notification of Client's need for assessment.

3. The SEP case manager shall complete the following activities for a LOC Screen:

a. Obtain all required information from the Client's medical provider including information required for target group determination;

b. Determine the Client's level of care needs during a face-to-face interview, preferably with the observation of the Client in his or her residential setting. Upon Department approval, the assessment may be completed by the case manager at an alternate location, via the telephone or using virtual technology methods. Such approval may be granted for situations in which face-to-face meetings would pose a documented safety risk to the case manager or Client (e.g. natural disaster, pandemic, etc.).;

c. Determine the ability and appropriateness of the Client's caregiver, family, or others, to provide the Client assistance in activities of daily living;

d. Determine the Client's service needs, including the Client's need for services not provided under HCBS-CMHS

e. If the Client is a resident of a nursing facility, determine the feasibility of deinstitutionalization;

f. Review service options based on the Client's needs, the potential funding sources, and the availability of resources;

g. Explore the Client's eligibility for publicly funded programs, based on the eligibility criteria for each program, in accordance with state rules;

h. View and document the current Assisted Living Residence license, if the Client lives, or plans to live, in a congregate facility as defined at Section 8.509.14 in order to assure compliance with the regulation at Section 5.509.11(B).

i. Determine and document Client preferences in program selection;

j. Complete documentation on the LOC Screen.

k. To de-institutionalize a Client who is in a nursing facility under payment by Medicaid, and with an existing nursing facility Level of Care Eligibility Determination with a completion date older than six (6) months,, the URC/SEP case manager shall complete a new LOC Screen and determine whether the client continues to meet the nursing facility level of care. The nursing facility staff shall notify the URC/SEP agency of the planned date of discharge and shall assign a new length of stay for HCBS if eligibility criteria are met. If a client leaves a nursing facility, and no one has notified the URC/SEP agency of the client's intent to apply for HCBS-CMHS, the case manager must complete a new LOC Screen and the Client shall be treated as an Applicant from the community rather than as a de-institutionalized Client.

l. It is the URC/SEP case manager's responsibility to assess the behaviors of the Client and assure that community placement is appropriate.

C. HCBS-CMHS DENIALS AND/OR DISCONTINUATIONS

1. If a Client is determined, at any point in the level of care eligibility determination process, to be ineligible for HCBS-CMHS according to any of the requirements at Section 8.509.15, the case manager shall refer the Client or the Client's designated representative to other appropriate services. Clients who are denied HCBS-CMHS services shall be notified of denials and appeal rights as follows:

a. Financial Eligibility

The income maintenance technician at the county department of social services shall notify the Applicant of denial for reasons of financial eligibility and shall inform the Applicant of appeal rights in accordance with Sections 3.840 and 3.850 of the Colorado Department of Human Services' Staff Manual Volume III at 9 CCR 2503-1. The case manager shall not attend the appeal bearing for a denial based on financial eligibility, unless subpoenaed, or unless requested by the state.

b. Level of Care AND Target Group

The URC shall notify the Applicant of denial for reasons related to determination of level of care AND target group eligibility and shall inform the Applicant of appeal rights in accordance with Section 8.057. The case manager shall not make judgments as to eligibility regarding level of care or target group and shall refer all Applicants who request a URC review to the URC, independently of any action that may be taken by the case manager in regard to other eligibility requirements, in accordance with the rest of this section. The case manager shall not attend the appeal hearing for a denial based on level of care or target group determination, unless subpoenaed, or unless requested by the state.

c. Receiving Services

The case manager shall notify the Applicant of denial, on Department-prescribed form, when the case manager determines that the Applicant does not meet the HCBS-CMHS eligibility requirements at Section 8.509.15 and shall inform the Applicant of appeal rights in accordance with Section 8.057, et. seq. The case manager shall also attend the appeal hearing to defend this denial action. A denial and appeal for this reason is independent of any action that may be taken by the URC in regard to level of care and target group determination.

d. Institutional Status

The case manager shall notify the Applicant of denial, on a Department-prescribed form, when the case manager determines that the Applicant does not meet the eligibility requirement at Section 8.509.15 and shall inform the Applicant of appeal rights in accordance with Section 8.057, et. seq. The case manager shall also attend the appeal hearing to defend this denial action. A denial and appeal for this reason is independent of any action that may be taken by the URC in regard to level of care and target group determination.

e. Cost-effectiveness

The case manager shall notify the Applicant of denial, on Department-prescribed form, when the case manager determines that the Applicant does not meet the eligibility requirement 8.509.15 and shall inform the Applicant of appeal rights in accordance with Section 8.057, et.seq. The case manager shall also attend the appeal hearing to defend this denial action. If the Applicant requests to receive less than the needed amount of services in order to become cost-effective, the case manager must assess the safety of the Applicant, and the competency of the Applicant to choose to live in an unsafe situation. If the case manager determines that the Applicant will be unsafe with the amount of services available and is not competent to choose to live in an unsafe situation, the case manager may deny HCBS-CMHS eligibility. To support a denial for safety reasons related to cost-effectiveness, the case manager must document the results of an Adult Protective Services assessment, a statement from the Client's physician attesting to the Client's mental competency status, and all other available information which will support the determination that the Client is unsafe and incompetent to make a decision to live in an unsafe situation; and, which will satisfy the burden of proof required of file case manager making the denial. Denials and appeals for reasons of cost-effectiveness, or safety related to cost-effectiveness, are independent of any action that may be taken by the URC in regard to level of care and target group determination.

f. Waiver Cap

The case manager shall notify the Applicant of denial, on a Department-prescribed form, when the waiver cap limiting the number of Clients who may be served under the terms of the approved waiver has been reached.

D. SERVICE PLANNING

1. Service Planning shall be defined in accordance with case planning at Section 8.393.2 and shall include, but not be limited to, the following tasks:

a. The identification and documentation of service plan goals and Client choices;

b. The identification and documentation of all services needed, including type of service, specific functions to be performed, frequency and amount of service, type of provider, finding source, and services needed but not available;

c. Documentation of the Client's choice of HCBS-CMHS services, nursing home placement, or other services, including a physical or digitally signed statement of choice from the Client;

d. Documentation that the Client was informed of the right to free choice of providers from among all the available and qualified providers for each needed service, and that the Client understands his/her right to change providers;

e. The formalization of the service plan agreement on a State-prescribed service plan form, including appropriate physical or digital signatures;

f. The arrangement for services by contacting service providers, coordinating service delivery, negotiating with the provider and the Client regarding service provision;

g. Referral to community resources as needed and development of resources for individual Clients if a resource is not available within the Client's community;

h. The explanation of complaint procedures to the Client.

2. The case manager shall meet the Client's needs, with consideration of the Client's choices, using the most cost-effective methods available.

E. CALCULATION OF CLIENT PAYMENT (PETI)

1. The case manager shall calculate the Client payment (PETI) for 300% eligible HCBS-CMHS Clients according to the following procedures:

a. For 300% eligible HCBS-CMHS Clients who are not Alternative Care Facility Clients, the case manager shall allow an amount equal to the 300% standard as the Client maintenance allowance. No other deductions are necessary and no form is required to be completed.

b. For 300% eligible Clients who are Alternative Care Facility Clients, the case manager shall complete a State-prescribed form which calculates the Client payment according to the following procedures:

1) An amount equal to the current Old Age Pension standard, including any applicable income disregards, shall be deducted from the Client's gross income to be used as the Client maintenance allowance, from which the state-prescribed Alternative Care Facility room and board amount shall be paid: and

2) For an individual with financial responsibility for only a spouse, an amount equal to the state Aid to the Needy Disabled (AND) standard, less the amount of any spouse's income, shall be deducted from the Client's gross income: or

3) For an individual with financial responsibility 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 less any income of the spouse and/or dependents (excluding income from part-time employment earnings of a dependent child who is either a full-time student of a part-time student as defined at Section 8.100.3.L.2.d.) shall be deducted from the Client's gross income; and

4) Amounts for incurred expenses for medical or remedial care for the individual that are not subject to payment by Medicare, Medicaid, or other third party shall be deducted from the Client's gross income as follows:

a) Health insurance premiums if health insurance coverage is documented in the eligibility system and the MMIS: deductible or co-insurance charges: and

b) Necessary dental care not to exceed amounts equal to actual expenses incurred: and

c) Vision and auditory care expenses not to exceed amounts equal to actual expenses incurred: and

d) Medications, with the following limitations:

(1) The need for such medications shall be documented in writing by the attending physician. For this purpose, documentation on the URC certification form shall be considered adequate. The documentation shall list the medication; state why it is medically necessary; be signed by the physician; and shall be renewed at least annually or whenever there is a change.

(2) Medications which may be purchased with the Client's Medical Identification Card shall not be allowed as deductions.

(3) Medications which may be purchased through regular Medicaid prior authorization procedures shall not be allowed.

(4) The full cost of brand-name medications shall not be allowed if a generic form is available at a lower price.

(5) Only the amount spent for medications which exceeds the current Old Age Pension Standard allowance for medicine chest expense shall be allowed as a deduction.

e) Other necessary medical or remedial care shall be deducted from the Client's gross income, with the following limitations:

(1) The need for such care shall be documented in writing by the attending physician. For this purpose, documentation on the URC certification form shall be considered adequate. 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.

(2) Any service, supply or equipment that is available under regular 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.

g) When 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.

5) Any remaining income-shall be applied to the cost of the Alternative Care Facility services, as defined at Section 8.495, and shall be paid by the Client directly to the facility; and

6) If there is still income remaining after the entire cost of Alternative Care Facility services is paid from the Client's income, the remaining income shall be kept by the Client and may be used as additional personal needs or for any other use that the Client desires, except that the Alternative Care Facility shall not charge more than the Medicaid rate for Alternative Care Facility services.

2. Case managers shall inform HCBS-CMHS Alternative Care Facility Clients of their Client payment obligation on a form prescribed by the state at the time of the first assessment visit by the end of each plan period; or within ten (10) working days whenever there is a significant change in the Client payment amount Significant change is defined as fifty dollars ($50) or more. Copies of Client payment forms shall be kept in the Client files at the case management agency, and shall not be mailed to the State or its agent, except as required for a prior authorization request, according to Section 8.509.31.G, or if requested by the state for monitoring purposes.

F. COST CONTAINMENT

The case manager shall determine whether the person can be served at or under the cost containment criteria of Section 8.509.14 for long-term care services for an individual recipient by using a state-prescribed Prior Authorization Request (PAR) form to:

1. Determine the maximum authorized costs for all HCBS-CMHS services for the period of time covered by the case plan and compute the average cost per day by dividing by the number of days in we case plan period; and

2. Determine that this average cost per day is less than or equivalent to the individual cost containment amount, which is calculated as follows:

a. Enter (in the designated space on the PAR form) the average monthly cost of nursing facility care; and

b. Subtract from that amount the Client's gross monthly income: and

c. Subtract from that amount the Client's Home Care Allowance grant amount, if any: and

d. Convert the remaining amount into a daily amount by dividing by 30.42 days. This amount is the daily individual cost containment amount which cannot be exceeded for the cost of HCBS services.

3. An individual Client whose service needs exceed the amount allowed under the Client's individual cost containment amount may choose to purchase additional services with personal income, but no Client shall be required to do so.

G. PRIOR AUTHORIZATION REQUESTS

1. The case manager shall complete and submit a prior authorization request (PAR) for all HCBS-CMHS services to the state or its agent in a timely manner in accordance with the STATE PRIOR AUTHORIZATION OF SERVICES in Section 8.485.90..

2. If a PAR includes a request for home modification services, the PAR shall also include all documentation listed at Section 8.493, HOME MODIFICATION.

3. If a PAR is for an Alternative Care Facility Client who is 300% eligible, the most recent state-prescribed Client Payment form shall be included in the PAR. All medical and remedial care requested as deductions on the Client Payment form must be listed on the long-terml Service Plan form.

4. The start date on the prior authorization request form shall never precede the start date of eligibility for HCBS-CMHS services, according to Section 8.509.16, START DATE.

5. The PAR shall not cover a period of time longer than the length of stay assigned by the URC.

6. A PAR does not have to be submitted for a non-diversion, as defined at 8.509.14(O).

7. If a PAR is returned to the case management agency for corrections, the corrected PAR must be returned to the State or its agent within thirty (30) calendar days after the case management agency receives the "Return to Provider" letter.

H. CASE MANAGEMENT AGENCY RESPONSIBILITY

1. The case management agency shall be financially responsible for any services which it authorized to be provided to the Client, or which continue to be rendered by a provider due to the case management agency's failure to timely notify the provider that the Client was no longer eligible for services, which did not receive approval by the state or its agent.

8.509.32ONGOING HCBS-CMHS CLIENTS

A. COORDINATION, MONITORING AND EVALUATION OF SERVICES

1. The coordination, monitoring, and evaluation of services for HCBS-CMHS Clients shall be in accordance with Section 8.393.2. In addition, the case manager shall:

a. Contact each Client quarterly, or more frequently, as determined by the Client's assessed needs. Contact may be at the Client's place of residence, by telephone, or other appropriate setting as determined by the Client's needs.

b. Review the LOC Screen and the PCSP with the client every six (6) months in person. Upon Department approval, contact may be completed by the case manager at an alternate location, via the telephone or using virtual technology methods. Such approval may be granted for situations in which face-to-face meetings would pose a documented safety risk to the case manager or Client (e.g. natural disaster, pandemic, etc.).

2. The case manager shall refer the Client for mental health services taking into account Client choice. The case manager shall coordinate case management activities for those Clients who are receiving mental health services from the Behavioral Health Organizations (BHO).

3. On-going case management shall include, but not be limited to the following tasks:

a. Review of the Client's case plan and service agreements;

b. Contact with the Client concerning whether services are being delivered according to the plan; and the Client's satisfaction with services provided;

c. Contact with service providers concerning service delivery, coordination, effectiveness, and appropriateness;

d. Contact with appropriate parties in the event any issues or complaints have been presented by the Client or others;

e. Conflict resolution and/or crisis intervention, as needed;

f. Informal assessment of changes in Client functioning, service effectiveness, service appropriateness, and service cost-effectiveness;

g. Notification of appropriate enforcement agencies, as needed; and

h. Referral to community resources, and arrangement for non-HCBS-CMHS services, as needed.

4. In the event, at any time throughout the case management process, the case manager suspects an individual to be a victim of abuse, neglect/self-neglect or exploitation, the case manager shall immediately refer the individual to the protective services section of the county department of social services of the individual's county of residence or the local law enforcement agency.

5. The case manager shall immediately report, to the appropriate agency, any information which indicates an overpayment, incorrect payment, or mis-utilization of any public assistance or Medicaid benefit. The case manager shall cooperate with the appropriate agency in any subsequent recovery process, in accordance with the Colorado Department of Human Services' Staff Manual Volume 3, Section 3.810.

B. REVISIONS

1. SERVICES ADDED TO THE SERVICE PLAN

a. Whenever a change in the service plan results in an increase or change in the services to be provided, the case manager shall submit a revised prior authorization request (PAR) to the state or its agent.

1) The revision PAR shall include the revised Long-term Care plan form and the revised Prior Authorization Request form.

2) The revised service plan form shall list the services being revised and shall state the reason for the revision. Services on the revised service plan form, plus all services on the original service plan form, must be entered on the revised Prior Authorization Request form, for purposes of reimbursement.

3) The dates on the revision must be identical to the dates of the original PAR, unless the purpose of the revision is to revise the PAR dates.

b. If a revised PAR includes a new request for home modification services, the revised PAR shall also include all documentation listed at Section 8.493.

2. SERVICES DECREASED ON THE SERVICE PLAN

a. If services are decreased without the Client's agreement according to Section 8.057.5, the case manager shall notify the Client of the adverse action and of appeal rights, according to Section 8.057, et. seq.

C. REASSESSMENT

1. The case manager shall complete a level of care Reassessment of each HCBS-CMHS Client before the end of the length of stay assigned by the URC at the Level of Care Eligibility Determination. The case manager shall initiate a Reassessment more frequently when warranted by significant changes that may affect HCBS-CMHS eligibility.

2. The case manager shall complete the Reassessment, utilizing the Department prescribed instrument.

3. Reassessment shall include, but not be limited to, the following activities:

a. Verify continuing Medicaid eligibility, including verification of an aid category that includes eligibility for long-term care benefits;

b. Evaluate service effectiveness, quality of care, appropriateness of services, and cost effectiveness;

c. Evaluate continuing need for the HCBS-CMHS program, and clearly document reasons for continuing HCBS; or terminate the Client's eligibility according to Section 8.509.32(E);

d. Ensure that all information needed from the medical provider for the LOC Screen is included.

e. Reassess the Client's level of care status, according to the procedures in Section 8.509.31(B);

f. Review the PCSP, including verification of whether services have been delivered according to the PCSP, and write a new PCSP, according to procedures at Section 8.509.31(D);

g. Refer the Client to community resources, as needed;

h. Submit a continued stay review PAR, in accordance with requirements at Section 8.509.31. For Clients who have been denied by the URC at continued stay review, and are eligible for services during the appeal, written documentation that an appeal is in progress may be used as a substitute for the Level of Care Eligibility Determination. Acceptable documentation of an appeal include:

(a) a copy of the request for reconsideration, or the request for appeal, signed by the Client and sent to the URC or to the Office of Administrative Courts;

(b) a copy of the notice of a scheduled hearing, sent by the URC or the Office of Administrative Courts to the Client; or

(c) a copy of the notice of a scheduled court date.

Copies of denial letters, and written statements from case managers, are not acceptable documentation that an appeal was actually filed and shall not be accepted as a substitute for the Level of Care Eligibility Determination. The length of the PAR on appeal cases may be up to one year, with the PAR being revised to the correct dates of eligibility at the time the appeal is resolved.

D. TRANSFER PROCEDURES

1. When Clients move, cases shall be transferred according to the current statewide Mental Health Services Continuity of Care Policy.

2. INTERCOUNTY TRANSFERS shall be in accordance with Section 8.393.31.

3. INTERDISTRICT TRANSFERS shall be in accordance with Section 8.393.32.

E. TERMINATION

1. Clients shall be terminated from the HCBS-CMHS program whenever they no longer meet one or more of the eligibility requirements at Section 8.509.15. Clients shall also be terminated from the program if they die, move out of state or voluntarily withdraw from the program.

2. Clients who are terminated from HCBS-CMHS because they no longer meet one or more of the eligibility requirements at Section 8.509.15 shall be notified of the termination and their appeal rights as follows:

a. Financial Eligibility

Procedures at Section 8.509.31, (C), shall be followed for terminations for this reason.

b. Level of Care AND Target Group

Procedures at Section 8.509.31, (C), shall be followed for terminations for this reason.

c. Receiving Services

Procedures at Section 8.509.31, (C), shall be followed for terminations for this reason

d. Institutional Status

Procedures at Section 8.509.31 shall be followed for terminations for this reason. In the case of termination for extended hospitalization, the case manager shall send the termination notice on the thirtieth (30) day of hospitalization. The termination shall he effective at the end of the advance notice period. If the Client returns home before the end of the advance notice period, the termination shall be rescinded.

e. Cost-effectiveness

Procedures at Section 8.509.31 shall be followed for terminations for this reason.

3. When Clients are terminated from HCBS-CMHS for reasons not related to eligibility requirements at Section 8.509.31, the case manager shall follow the procedures below:

a. Death

Clients who die shall be terminated from the HCBS-CMHS program, effective upon the day after the date of death.

b. Moved out of State

Clients who move out of Colorado shall be terminated from the HCBS-CMHS program, effective upon the day after the date of the move. The case manager shall send the Client a state-prescribed Advisement Letter advising the Client that the case has been closed. Clients who leave the state on a temporary basis, with intent to return to Colorado, according to the Income Maintenance Staff Manual Section 1140.2, shall not be terminated from the HCBS-CMHS program unless one or more of the other eligibility criteria, as specified at Section 8.509.15 is no longer met.

c. Voluntary Withdrawal from the Program

Clients who voluntarily withdraw from the HCBS-CMHS program shall be terminated from the program, effective upon the day after the date on which the Client either requests in writing to withdraw from the program, or the date on which the Client enters a nursing facility. The case manager shall send the Client a state-prescribed Advisement Letter advising the Client that the case has been closed.

4. The case manager shall provide appropriate referrals to other community resources, as needed, upon termination.

5. The case manager shall immediately notify all providers on the case plan of any terminations.

6. If a case is terminated before an approved PAR has expired, the case manager shall submit, to the state or its agent, a copy of the current prior authorization request form, on which the end date is adjusted (and highlighted in some manner on the form); and the reason for termination shall be written on the form.

8.509.33OTHER CASE MANAGEMENT REQUIREMENTS

A. COMMUNICATION

In addition to any communication requirements specified elsewhere in these rules, the case manager shall be responsible for the following communications:

1. The case manager shall inform the income maintenance technician of any and all changes in the Client's participation in HCBS-CMHS and shall provide the technician with copies of the first page of all URC-approved ULTC-100.2 forms.

2. The case manager shall inform all Alternative Care Facility Clients of their obligation to pay the full and current state-prescribed room and board amount, from their own income, to the Alternative Care Facility provider.

3. If the Client has an open service case file at the county department of social services, the case manager shall keep the Client's caseworker informed of the Client's status and shall participate in mutual staffing of the Client's case.

4. The case manager shall inform the Client's physician of any significant changes in the Client's condition or needs.

5. Within five (5) working days of receipt, from the State or it; agent, of the approved Prior Authorization Request form, the case manager shall provide copies to all the HCBS-CMHS providers in the case plan.

6. The case manager shall notify the URC, on a form prescribed by the state of the outcome of all non-diversions, as defined at Section 8.509.14.

7. The case manager shall report to the Colorado Department of Public Health and Environment any congregate facility which is not licensed.

8. The case management agency shall notify the state of any Client appeals which are initiated as a result of denials or terminations made by the case management agency.

B. CASE RECORDING/DOCUMENTATION

1. The case management agency shall maintain records on every individual for whom intake was conducted, including a copy of the intake form. The records must indicate the dates on which the referral was first received, and the dates of all actions taken by the case management agency. Reasons for all assessment decisions and program targeting decisions must be clearly stated in the records.

2. The case record shall include:

a. Identifying information, including the state identification (Medicaid) number, and

b. All state-required forms; and

c. Documentation of all case management activity required by these regulations.

3. Case management documentation shall meet all the following standards:

a. A separate case record shall be maintained for each Client receiving services in the Home and Community-based Services for Community Mental Health Supports Program.

b. Documentation shall be legible;

c. Entries shall be written at the time of the activity or shortly thereafter,

d. Entries shall be dated according to the date of the activity, including the year;

e. Entries shall be made in permanent ink or digital signature;

f. The Client shall be identified on every page;

g. The person making each entry shall be identified;

h. Entries shall be concise, but shall include all pertinent information;

i. All information regarding a Client shall be kept together for easy access and review by case managers, supervisors, program monitors and auditors;

j. The source of all information shall be recorded, and the record shall clarify whether information is observable and objective fact, or is a judgment or conclusion on the part of anyone;

k. All persons and agencies referenced in the documentation shall be identified by name and by relationship to the Client;

l. All forms prescribed by the State shall be filled out by the case manager to be complete, correct and accurate.

m. If the individual is unable to sign a form requiring his/her signature because of a medical condition, a digital signature or any mark the individual is capable of making will be accepted in lieu of a signature. If the individual is not capable of making a mark or performing a digital signature, the physical or digital signature of guardian or other authorized representative will be accepted.

4. All records shall be kept for the period of time specified in the case management agency contract, and shall be made available to the state as specified in the contract.

8.509.40HCBS-CMHS PROVIDERS

A. Any provider agency with a valid contract to provide HCBS-EBD services, according to Section 8.487, shall be deemed certified to provide the same services to HCBS-CMHS Clients.

8.509.50MENTAL HEALTH TRANSITIONAL LIVING HOMES

A. 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; and

b. 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; and

g. 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; and

iv. 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;

ix. Criminal activity;

x. Incidents or reports of actions by member receiving services that are unusual and require review; and

xi. 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;

v. Incident type;

vi. Date, time, and duration of incident;

vii. Location of incident;

viii. Persons involved;

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; and

xv. 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.

v. Symptom Management.

vi. Behavior Management.

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 service

iii. 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.

10 CCR 2505-10-8.509

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

46 CR 17, September 10, 2023, effective 9/30/2023

46 CR 21, November 10, 2023, effective 11/30/2023