10 Colo. Code Regs. § 2505-10-8.517

Current through Register Vol. 47, No. 16, August 25, 2024

Section 10 CCR 2505-10-8.517 - [Repealed effective 9/14/2024] HOME AND COMMUNITY-BASED SERVICES FOR THE COMPLEMENTARY AND INTEGRATIVE HEALTH WAIVER

8.517.1HCBS-CIH WAIVER SERVICES

8.517.1.ASERVICES PROVIDED

1. Acupuncture (CIHS)

2. Adult Day Services

3. Chiropractic (CIHS)

4. Consumer Directed Attendant Support Services (CDASS)

5. Electronic Monitoring

6. Home Delivered Meals

7. Home Modification

8. Homemaker Services

9. In-Home Support Services

10. Life Skills Training (LST)

11. Massage Therapy (CIHS)

12. Non-Medical Transportation

13. Peer Mentorship

14. Personal Care Services

15. Respite Care

16. Transition Setup

8.517.1.BDEFINITIONS OF SERVICES

1. Acupuncture (CIHS) means services as defined at Section 8.517.2.A.

2. Adult Day Services means services as defined at Section 8.491.

3. Chiropractic (CIHS) means services as defined at Section 8.517.2.B.

4. Complementary and Integrative Health Services (CIHS) means services as defined at Section 8.517.B.E.

5. Consumer Directed Attendant Support Services (CDASS) means services as defined at Section 8.510.

6. Electronic Monitoring means services as defined at Section 8.488.

7. Home Delivered Meals means services as defined at Section 8.553.

8. Home Modification means services as defined at Section 8.493.

9. Homemaker Services means services as defined at Section 8.490.

10. In-Home Support Services means services as defined at Section 8.552.

11. Life Skills Training (LST) means services as defined at Section 8.553.

12. Massage Therapy (CIHS) means services as defined at Section 8.517.2.H.

13. Non-Medical Transportation means services as defined at Section 8.494.

14. Peer Mentorship means services as defined at Section 8.553.

15. Personal Care Services means services as defined at Section 8.489.

16. Respite Care means services as defined at Section 8.492.

17. Transition Setup means services as defined at Section 8.553.

8.517.2GENERAL DEFINITIONS

A. Acupuncture (CIHS) means the insertion of needles and/or manual, mechanical, thermal, electrical, and electromagnetic treatment to stimulate specific anatomical tissues for the promotion, maintenance and restoration of health and prevention of disease both physiological and psychological. During an acupuncture treatment, dietary advice and therapeutic exercises may be recommended in support of the treatment.

B. Chiropractic (CIHS) means the use of manual adjustments (manipulation or mobilization) of the spine or other parts of the body with the goal of correcting and/or improving alignment, neurological function, and other musculoskeletal problems. During a chiropractic treatment, nutrition, exercise, and rehabilitative therapies may be recommended in support of the adjustment.

C. Complementary and Integrative Health Care Plan means the plan developed prior to the delivery of Complementary and Integrative Health Services in accordance with Section 8.517.1 1.D.

D. Complementary and Integrative Health Provider means an individual or agency certified annually by the Department to have met the certification standards listed at Section 8.517.11.

E. Complementary and Integrative Health Services (CIHS) means Acupuncture, Chiropractic, and Massage Therapy.

F. Emergency Systems means procedures and materials used in emergent situations and may include, but are not limited to, an agreement with the nearest hospital to accept patients; an Automated External Defibrillator; a first aid kit; and/or suction, AED, and first aid supplies.

G. Individual Cost Containment Amount means the average cost of services for a comparable population institutionalized at the appropriate level of care, as determined annually by the Department.

H. Massage Therapy (CIHS) means the systematic manipulation of the soft tissues of the body, (including manual techniques of gliding, percussion, compression, vibration, and gentle stretching) for the purpose of bringing about beneficial physiologic, mechanical, and/or psychological changes.

8.517.3LEGAL BASIS

The Home and Community-based Services for Complementary and Integrative Health (HCBS-CIH) waiver 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-CIH program is also authorized under state law at C.R.S. section 25.5-6-1301 et seq. - as amended.

8.517.4SCOPE AND PURPOSE

8.517.4.A. The Home and Community-based Services for Complementary and Integrative Health (HCBS-CIH) waiver provides assistance to individuals living with a qualifying condition of a spinal cord injury, multiple sclerosis, a brain injury, spina bifida, muscular dystrophy, or cerebral palsy with the inability for independent ambulation directly resulting from one of these conditions that require long-term supports and services in order to remain in a community setting.

8.517.4.B. The HCBS-CIH waiver provides an opportunity to study the effectiveness of Complementary and Integrative Health Services and the impact the provision of these service may have on the utilization of other HCBS-CIH waiver and/or acute care services.

8.517.4.C. An independent evaluation shall be conducted no later than January 1, 2025 to determine the effectiveness of the Complementary and Integrative Health Services.

8.517.5CLIENT ELIGIBILITY

8.517.5.A. ELIGIBLE PERSONS

Home and Community-based Services for Complementary and Integrative Health (HCBS-CIH) waiver services shall be offered only to individuals who meet all of the following eligibility requirements:

1. Individuals shall be aged 18 years or older.

2. Individuals shall have a qualifying condition of a spinal cord injury (traumatic or nontraumatic), multiple sclerosis, a brain injury, spina bifida, muscular dystrophy, or cerebral palsy with the inability for independent ambulation directly resulting from one of these conditions as defined by broad diagnoses related to each condition within the most current version of the International Classification of Diseases (ICD) at the time of assessment.

3. Individuals must have been determined to have an inability for independent ambulation resulting from the qualifying condition as identified by the case manager through the assessment process. The inability for independent ambulation means:

a. The individual does not walk, and requires use of a wheelchair or scooter in all settings, whether or not they can operate the wheelchair or scooter safely, on their own, OR;

b. The individual does walk, but requires use of a walker or cane in all settings, whether or not they can use the walker or cane safely, on their own, OR;

c. The individual does walk but requires "touch" or "stand-by" assistance to ambulate safely in all settings.

8.517.5.C LEVEL OF CARE CRITERIA

Individuals shall require long-term support services at a level of care comparable to services typically provided in a nursing facility or hospital.

8.517.5.D NEED FOR HOME AND COMMUNITY-BASED SERVICES FOR COMPLEMENTARY AND INTEGRATIVE HEALTH (HCBS-CIH) WAIVER SERVICES

1. Only individuals that currently receive Home and Community-based Services for Complementary and Integrative Health (HCBS-CIH) waiver services, or that have agreed to accept HCBS-CIH services as soon as all other eligibility criteria have been met, are eligible for the HCBS-CIH waiver.

a. Case management is not a HCBS-CIH service and shall not be used to satisfy this requirement.

b. The desire or need for any Medicaid services other than HCBS-CIH waiver services, as listed at Section 8.517.1, shall not satisfy this eligibility requirement.

2. Individuals that have not received at least one (1) HCBS-CIH waiver service for a period greater than 30 consecutive days shall be discontinued from the waiver.

8.517.5.E EXCLUSIONS

1. Individuals who are residents of nursing facilities or hospitals are not eligible to receive Home and Community-based Services for Complementary and Integrative Health (HCBS-CIH) waiver services.

2. HCBS-CIH Clients that enter a nursing facility or hospital may not receive HCBS-CIH waiver services while admitted to the nursing facility or hospital.

a. HCBS-CIH Clients admitted to a nursing facility or hospital for 30 consecutive days or longer shall be discontinued from the HCBS-CIH program.

b. HCBS-SCI Clients entering a nursing facility for Respite Care as an HCBS-CIH service shall not be discontinued from the HCBS-CIH program.

8.517.5.F COST CONTAINMENT AND SERVICE ADEQUACY

1. Individuals shall not be eligible for the Home and Community-based Services for Complementary and Integrative Health (HCBS-CIH) waiver if the case manager determines any of the following during the initial assessment and service planning process:

a. The individual's needs cannot be met within the Individual Cost Containment Amount.

b. The individual's needs are more extensive than HCBS-CIH waiver services can support and/or that the individual's health and safety cannot be assured in a community setting.

2. Individuals shall not be eligible for the HCBS-SCI waiver at reassessment if the case manager determines the individual's needs are more extensive than HCBS-CIH waiver services are able to support and/or that the individual's health and safety cannot be assured in a community setting.

3. Individuals may be eligible for the HCBS-CIH waiver at reassessment if the case manager determines that HCBS-CIH waiver services are able to support the individual's needs and the individual's health and safety can be assured in a community setting.

a. If the case manager expects that the services required to support the individual's needs will exceed the Individual Cost Containment Amount, the Department or its agent will review the support plan to determine if the individual's request for services is appropriate and justifiable based on the individual's condition.

i) Individuals may request of the case manager that existing services remain intact during this review process.

ii) In the event that the request for services is denied by the Department or its agent, the case manager shall provide the individual with:

1) Long-Term Care Notice of Action Form (LTC-803), informing the Client of the denial and providing the Client's appeal rights pursuant to Section 8.057; and

2) Alternative options to meet the individual's needs that may include, but are not limited to, nursing facility placement.

8.517.6WAITING LIST

1. The number of Clients who may be served through the Home and Community-based Services for Complementary and Integrative Health (HCBS-CIH) waiver during a fiscal year may be limited by the federally approved waiver.

2. Individuals determined eligible for the HCBS-CIH waiver who cannot be served within the federally approved waiver capacity limits shall be eligible for placement on a waiting list.

3. The waiting list shall be maintained by the Department.

4. The case manager shall ensure the individual meets all eligibility criteria as set forth at Section 8.517.5 prior to notifying the Department to place the individual on the waiting list.

5. The date the case manager determines an individual has met all eligibility requirements as set forth at Section 8.517.5 is the date the Department will use for the individual's placement on the waiting list.

6. When an eligible individual is placed on the waiting list for the HCBS-CIH waiver, the case manager shall provide a written notice of the action in accordance with section 8.057 et seq.

7. As openings become available within the capacity limits of the federally approved waiver, individuals shall be considered for the HCBS-CIH waiver in the order of the individual's placement on the waiting list

8. When an opening for the HCBS-CIH waiver becomes available the Department will provide written notice to the Case Management Agency.

9. Within ten business days of notification from the Department that an opening for the HCBS-CIH waiver is available the Case Management Agency shall:

a. Reassess the individual for level of care using the Department's prescribed instrument if more than six months has elapsed since the previous assessment.

b. Update the existing level of care assessment in the official Client record if less than six months has elapsed since the date of the previous assessment.

c. Reassess for eligibility criteria as set forth at 8.517.5.

d. Notify the Department of the individual's eligibility status.

8.517.7START DATE FOR SERVICES

8.517.7.A. The start date of eligibility for Home and Community-Based Services for Complementary and Integrative Health (HCBS-CIH)waiver services shall not precede the date that all of the requirements at Section 8.517.5, have been met. The first date for which HCBS-CIH waiver services may be reimbursed shall be the later of the following:

1. The date at which financial eligibility is effective.

2. The date at which the level of care and targeting criteria are certified.

3. The date at which the individual agrees to accept services and signs all necessary intake and service planning forms.

4. The date of discharge from the hospital or nursing facility.

8.517.8CASE MANAGEMENT FUNCTIONS

8.517.8.A. The requirements at Section 8.486 shall apply to the Case Management Agencies performing the case management functions of the Home and Community-based Services for Complementary and Integrative Health (HCBS-CIH) waiver.

8.517.9PRIOR AUTHORIZATION OF SERVICES

8.517.9.A. All Home and Community-based Services for Complementary and Integrative Health (HCBS-CIH) waiver services must be prior authorized by the Department or its agent.

8.517.9.B. The Department shall develop the Prior Authorization Request (PAR) form to be used by case managers in compliance with all applicable regulations.

8.517.9.C. Claims for services are not reimbursable if:

1. Services are not consistent with the Client's documented medical condition and functional capacity;

2. Services are not medically necessary or are not reasonable in amount, scope, frequency, and duration;

3. Services are duplicative of other services included in the Client's Support Plan;

4. The Client is receiving funds to purchase services; or

5. Services total more than 24 hours per day of care.

8.517.9.D. Revisions to the PAR that are requested six months or more after the end date shall be disapproved.

8.517.9.E. Payment for HCBS-CIH waiver services is also conditional upon:

a. The Client's eligibility for HCBS-CIH waiver services;

b. The provider's certification status; and

c. The submission of claims in accordance with proper billing procedures.

8.517.9.F. Prior authorization of services is not a guarantee of payment. All services must be provided in accordance with regulation and necessary to meet the Client's needs.

8.517.9.G. Services requested on the PAR shall be supported by information on the Long-term Care Support Plan and written documentation from the income maintenance technician of the Client's current monthly income.

8.517.9.H. The PAR start date shall not precede the start date of HCBS-CIH eligibility in accordance with Section 8.517.7.

8.517.9.I. The PAR end date shall not exceed the end date of the HCBS-CIH eligibility certification period.

8.517.10PROVIDER AGENCIES

8.517.10.A. HCBS-SCI providers shall abide by all general certification standards, conditions, and processes established at Section 8.487.

8.517.11COMPLEMENTARY AND INTEGRATIVE HEALTH SERVICES

Complementary and Integrative Health Services are limited to Acupuncture, Chiropractic Care, and Massage Therapy as defined at Section 8.517.2.

8.517.11.A. Inclusions

1. Acupuncture used for the treatment of conditions or symptoms related to the Client's qualifying condition and inability to independently ambulate.

2. Chiropractic Care used for the treatment of conditions or symptoms related to the Client's qualifying condition and inability to independently ambulate.

3. Massage Therapy used for the treatment of conditions or symptoms related to the Client's qualifying condition and inability to independently ambulate.

8.517.11.B. Exclusions / Limitations

1. Complementary and Integrative Health Services shall be provided only for the treatment of conditions or symptoms related to the Client's qualifying condition and inability to independently ambulate.

2. Complementary and Integrative Health Services shall be limited to the Client's assessed need for services as determined by the Complementary and Integrative Health Provider and documented in the Complementary and Integrative Health Care Plan.

3. Complementary and Integrative Health Services shall be provided in an approved outpatient setting in accordance with 8.517.11.C .2 or in the Client's residence.

4. Complementary and Integrative Health Services shall be provided only by a Complementary and Integrative Health Provider certified by the Department of Health Care Policy and Financing to have met the certification standards listed at Section 8.517.11.C.

5. Clients receiving Complementary and Integrative Health Services shall participate in an independent evaluation to determine the effectiveness of the services.

6. The Complementary and Integrative Health Services benefit is limited as follows:

a. A Client may receive each of the three individual Complementary and Integrative Health Services on a single date of service.

b. A Client shall not receive more than four (4) units of each individual Complementary and Integrative Health Service on a single date of service.

c. A Client shall not receive more than 204 units of a single Complementary and Integrative Health service during a 365-day certification period.

d. A Client shall not receive more than 408 combined units of all Complementary and Integrative Health Services during a 365-day certification period.

8.517.11.C. Certification Standards

1. Organization and Staffing

a. Complementary and Integrative Health Services must be provided by licensed, certified, and/or registered individuals operating within the applicable scope of practice.

b. Acupuncturists shall be licensed by the Department of Regulatory Agencies, Division of Registrations as required by the Acupuncturists Practice Act (C.R.S § 12-200-101 et seq) and have at least (1) year experience practicing Acupuncture at a rate of 520 hours per year; OR (1) year of experience working with individuals with paralysis or other long term physical disabilities.

c. Chiropractors shall be licensed by the State Board of Chiropractic Examiners as required by the Chiropractors Practice Act (C.R.S. § 12-215-101 et seq) and have at least (1) year experience practicing Chiropractic at a rate of 520 hours per year; OR (1) year of experience working with individuals with paralysis or other long term physical disabilities.

d. Massage Therapists shall be registered by the Department of Regulatory Agencies, Division of Registrations as required by the Massage Therapy Practice Act (C.R.S. § 12-235-101, et seq) and have at least (1) year experience practicing Massage Therapy at a rate of 520 hours per year; OR (1) year of experience working with individuals with paralysis or other long term physical disabilities.

2. Environmental Standards for Complementary and Integrative Health Services provided in an outpatient setting.

a. Complementary and Integrative Health Providers shall develop a plan for infection control that is adequate to avoid the sources of and prevent the transmission of infections and communicable diseases. They shall also develop a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel. Sterilization procedures shall be developed and implemented in necessary service areas.

b. Policies shall be developed and procedures implemented for the effective control of insects, rodents, and other pests.

c. All wastes shall be disposed in compliance with local, state and federal laws.

d. A preventive maintenance program to ensure that all essential mechanical, electrical and patient care equipment is maintained in safe and sanitary operating condition shall be provided. Emergency Systems, and all essential equipment and supplies shall be inspected and maintained on a frequent or as needed basis.

e. Housekeeping services to ensure that the premises are clean and orderly at all times shall be provided and maintained. Appropriate janitorial storage shall be maintained.

f. Outpatient settings shall be constructed and maintained to ensure access and safety.

g. Outpatient settings shall demonstrate compliance with the building and fire safety requirements of local governments and other state agencies.

3. Failure to comply with the requirements of this rule may result in the revocation of the Complementary and Integrative Health Provider certification.

8.517.11.D COMPLEMENTARY AND INTEGRATIVE HEALTH CARE PLAN

1. Complementary and Integrative Health Providers shall:

a. Guide the development of the Complementary and Integrative Health Care Plan in coordination with the client and/or client's representative.

b. Recommend the appropriate modality, amount, scope, and duration of the Complementary and Integrative Health Service(s) within the established limits as listed at 8.517.11.B.

c. Recommend only services that are necessary and appropriate and will be rendered by the recommending Complementary and Integrative Health Provider.

d. Maintain client records as established at Section 8.487.16 . Client records shall be made available to the Department or designated entity upon request and demonstrate the completion of Complementary and Integrative Health Providers requirements above.

2. The Complementary and Integrative Health Provider shall reassess the Complementary and Integrative Health Care Plan annually or more frequently as necessary. The reassessment shall include a visit with the client.

3. The Complementary and Integrative Health Care Plan shall be developed using Department prescribed form(s) or template(s).

4. The Complementary and Integrative Health Care Plan shall include the amount, scope, and duration of recommended Complementary and Integrative Health Services (CIHS).

5. Recommendations for CIHS on the Complementary and Integrative Health Care Plan will guide case managers in completing the Prior Authorization Request (PAR).

6. CIHS will be added to the PAR only if recommended in the Complementary and Integrative Health Care Plan and agreed to by the client.

10 CCR 2505-10-8.517

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

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