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Section 10 CCR 2505-10-8.519 - [Effective until 9/15/2024] Case Management

10 Colo. Code Regs. § 2505-10-8.519

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Current through Register Vol. 47, No. 16, August 25, 2024
Section 10 CCR 2505-10-8.519 - [Effective until 9/15/2024] Case Management
8.519.1Definitions
A. Adverse Action means a denial, reduction, termination, or suspension from a long-term service and support program or service.
B. Algorithm means a formula that establishes a set of rules that precisely defines a sequence of operations. An algorithm is used to assign Clients into one of six support levels in the Home and Community-based Services for Persons with Developmental Disabilities (HCBS-DD) and Home and Community Based Services- Supported Living Services (HCBS-SLS) waivers.
C. Assessment means as defined in Section 8.390.1 DEFINITIONS.
D. Authorized Representative means an individual designated by a Client or by the parent or guardian of the Client, if appropriate, to assist the Client 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) as defined in Section 8.510.1.
E. Business Day means any day in which the state is open and conducting business, but shall not include Saturday, Sunday, or any day in which the state observes on of the holidays listed in Section 24-11-101(1), C.R.S.
F. Case Manager means a person who provides case management services and meets all regulatory requirements for Case Managers.
G. Case Management means as defined in Section 8.390.1 DEFINITIONS.
H. Case Management Agency (CMA) means a public or private not-for-profit or for-profit agency that meets all applicable state and federal requirements and is certified by the Department to provide case management services for specific Home and Community-Based Services waivers pursuant to Section 25.5-10-209.5, C.R.S. and pursuant to a provider participation agreement with the state department.
I. Certification means the process by which an agency is approved by the Department to provide case management which includes the submission and approval of a Medicaid Provider Agreement along with submission of verification that the agency meets the qualifications as set forth in Section 8.519.
J. Client means an individual who meets long-term services and supports eligibility requirements and has been approved for and agreed to receive Home and Community-Based Services (HCBS).
K. Client Representative means a person who is designated by the Client to act on the Client's behalf. A Client Representative may be:
(A) a legal representative including, but not limited to a court-appointed guardian, a parent of a minor child, or a spouse; or
(B) an individual, family member or friend selected by the Client to speak for or act on the Client's behalf.
L. Community Centered Board means a private corporation, for-profit or not-for-profit that is designated pursuant to Section 25.5-10-209, C.R.S., responsible for, but not limited to conducting Developmental Disability determinations, waiting list management Level of Care Evaluations for Home and Community-Based Service waivers specific to individuals with intellectual and developmental disabilities, and management of State Funded programs for individuals with intellectual and developmental disabilities.
M. Conflict-Free Case Management means, pursuant to 42 CFR § 441.301(c)(1)(vi), case management services provided to a Client enrolled in a Home and Community-Based Services waiver that are provided by a Case Management Agency that is not the same agency that provides services and supports to that person.
N. Corrective Action Plan shall be as defined at Section 8.390.1. DEFINITIONS.
O. Critical Incident means incidents or allegations involving Clients receiving services to include mistreatment, abuse, neglect, exploitation, illness/injury, death, damage to consumer's property/theft, medication management issues, criminal activity, unsafe housing/displacement, and missing persons.
P. Department means the Colorado Department of Health Care Policy and Financing, the Single State Medicaid Agency.
Q. Developmental Delay means as defined in Section 8.600.4.
R. Developmental Disability means as defined in Section 8.600.4.
S. Executive Director means the Executive Director of the Colorado Department of Health Care Policy and Financing unless otherwise indicated.
T. Financial Eligibility means the eligibility criteria for a publicly funded program, based on the individual's financial circumstances, including income and resources, if applicable.
U. Guardian means an individual at least twenty-one years of age, resident or non-resident, who has qualified as a guardian of a minor or incapacitated person pursuant to appointment by a parent or by the court. The term includes a limited, emergency, and temporary substitute guardian but not a guardian ad litem Section 15-14-102(4), C.R.S.
V. Guardian ad litem or GAL means a person appointed by a court to act in the best interests of a child involved in a proceeding under title19, C.R.S., or the "School Attendance Law of 1963," set forth in article 33 of title 22, C.R.S.
W. Home and Community-based Services (HCBS) waivers means services and supports authorized through a 1915(c) waiver of the Social Security Act and provided in community settings to a Client who requires a Level of Care that would otherwise be provided in a hospital, nursing facility, or Intermediate Care Facility for individuals with Intellectual Disabilities (ICF-IID).
X. Incident means an injury to a person receiving services; lost or missing persons receiving services; medical emergencies involving persons receiving services; hospitalizations of persons receiving services; death of persons receiving services; errors in medication administration; incidents or reports of actions by persons receiving services that are unusual and require review; allegations of abuse, mistreatment, neglect, or exploitation; use of safety control procedures; use of emergency control procedures; and stolen personal property belonging to a person receiving services.
Y. Information Management System (IMS) means as defined in Section 8.390.1 DEFINITIONS.
Z. Interdisciplinary Team (IDT) means a group of people convened by a certified Case Management Agency that includes the person receiving services, the parent or guardian of a minor, guardian or an authorized representative, as appropriate, the person who coordinates the provision of services and supports, and others as chosen by the person receiving services, who are assembled to work in a cooperative manner to develop or review the PCSP.
AA.Legally Responsible Persons means the parent of a minor child, or the Client's spouse,
BB. Level of Care Eligibility Determination means as defined in Section 8.390.1 DEFINITIONS.
CC. Level of Care Eligibility Determination Screen means as defined in Section 8.390.1 DEFINITIONS.
DD. Long-Term Services and Supports (LTSS) means the services and supports used by individuals of all ages with functional limitations and chronic illnesses who need assistance to perform routine daily activities such as bathing, dressing, preparing meals, and administering medications.
EE.Medicaid Eligible means an Applicant or Client meets the criteria for Medicaid benefits based on the Applicant's financial determination and disability determination when applicable.
FF.Organized Health Care Delivery System (OHCDS) means a public or privately managed service organization that is designated as a Community Centered Board and contracts with other qualified providers to furnish services authorized in the Home and Community-based Services for Persons with Developmental Disabilities (HCBS-DD), HCBS-Supported Living Services (HCBS-SLS) and HCBS-Children's Extensive Supports (HCBS-CES) waivers.
GG. Parent means the biological or adoptive parent.
HH. Performance and Quality Review means a review conducted by the Department or its contractor at any time but no less than the frequency as specified in the approved waiver application. To include a review of required case management services performed by the agency to ensure quality and compliance with all requirements. The agency shall provide all requested information and documents as requested by the Department or by its contractor.
II. Person-Centered Support Plan (PCSP) means as defined in Section 8.390.1 DEFINITIONS.
JJ. Person-Centered Support Planning means as defined in Section 8.390.1 DEFINITIONS.
KK. Prior Authorization Requests (PAR) means approval for an item or service that is obtained in advance either from the Department, a state fiscal agent or the Case Management Agency.
LL. Professional Medical Information Page (PMIP) means as defined in Section 8.390.1 DEFINITIONS.
MM. Provider for the purpose of this section means any person, group or entity approved to render services or provide items to a Client enrolled in an HCBS waiver program.
NN. Regional Center means a facility or program operated directly by the Department of Human Services which provides services and supports to Clients with intellectual and developmental disabilities.
OO. Retrospective Review means the Department or the Department's contractor's review after services and supports are provided to ensure the Client received services according to the PCSP and that the Case Management Agency complied with the requirements set forth in statute, waiver, and regulations.
PP. Service Plan Authorization Limit (SPAL) means an annual upper payment limit of total funds available to purchase services to meet the Client's ongoing needs. Purchase of services not subject to the SPAL are set forth at Section 8.500.102.B. A specific limit is assigned to each of the six support levels in the HCBS-SLS waiver. The SPAL is determined by the Department based on the annual appropriation for the HCBS-SLS waiver, the number of Clients in each level, and projected utilization.
QQ. Supports Intensity Scale (SIS) means the standardized assessment tool that gathers information from a semi-structured interview of respondents who know the Client well. It is designed to identify and measure the practical support requirements of adults with intellectual and developmental disabilities.
RR. Support Level means a numeric value determined using an algorithm that places Clients into groups with other Clients who have similar overall support needs.
SS. Targeted Case Management (TCM) means case management services provided to Clients enrolled in the HCBS-CES, HCBS- Children Habilitation Residential Program (CHRP), HCBS-DD, and HCBS-SLS waivers in accordance with Section 8.760 et seq, Targeted case management includes facilitating enrollment, locating, coordinating and monitoring needed HCBS waiver services and coordinating with other non-waiver resources, including, but not limited to medical, social, educational and other resources to ensure non-duplication of waiver services and the monitoring of effective and efficient provision of waiver services across multiple funding sources. Targeted case management includes the following activities Assessment and periodic Reassessment, development and periodic revision of a PCSP, referral and related activities, and monitoring.
TT. Waiver Services means those optional Medicaid services defined in the current federally approved HCBS waiver document and do not include Medicaid state plan services.
8.519.2Case Management Agency Qualifications
8.519.2.A. A CMA must meet the following qualifications:
1. Have a physical location in Colorado and provide all required case management activities for the counties in which the agency elects to serve.
2. Be a public or private not for profit or for profit agency that meets all applicable state and federal requirements and is certified by the Department to provide case management services pursuant to Section 25.5-10-209.5, C.R.S. Case management agencies that are private not for profit must have certification from the state of Colorado or a letter from the Department of the Treasury, internal revenue service classifying the agency as a private not for profit agency.
3. Provide proof that the agency staff meets all Case Manager qualifications.
4. As an agency, have a minimum of two years of agency experience in assisting high-risk, low income individuals, to obtain medical, social, educational and/or other services. Case Management Agencies who were previously affiliated with an agency providing HCBS case management prior to August 30, 2019 are exempt from this requirement.
5. Demonstrate the agency does not have any fiduciary relationship with an agency who provides HCBS waiver services. Agencies providing HCBS case management prior to August 30, 2019 are exempt from this requirement.
6. Provide case management to Clients who select the agency as long as the Client reside in the county for which the agency has elected to provide case management services
7. Possess the administrative capacity to deliver case management services in accordance with state and federal requirements.
8. Have established community referral systems and demonstrate linkages and the ability to make community referrals for services with other agencies.
9. Demonstrate ability to meet all state and federal requirements governing the participation of case management agencies in the state Medicaid program, including but not limited to the ability to meet state and federal requirements for documentation, billing and auditing.
10. Have one-month reserve financial capacity to maintain operations. HCBS case management agencies providing case management services in Colorado prior to August 30,2019 are exempt from this requirement.
11. Demonstrate that the agency has financial reserves for one month of expenditures to cover costs associated with the number of Clients expected through their catchment area, including reserves to cover salaries and costs for Case Managers, and Clients. All agencies are required to submit an audited financial statement to the Department for review annually. Agencies providing HCBS case management services in Colorado prior to August 30, 2019 are exempt from this one-month financial requirement.
12. Possess and maintain adequate liability insurance (including automobile insurance, professional liability insurance and general liability insurance) to meet the Department's minimum requirements.
13. Shall not be an approved provider agency providing direct services to individuals who are enrolled in HCBS waivers. Agencies providing HCBS case management prior to August 30, 2019 are exempt from this requirement
8.519.3Functions of all Case Management Agencies
8.519.3.A Case Management Agencies must:
1. Maintain sufficient documentation of case management activities performed and to support claims.
2. Not provide guardianship services for any Client enrolled in an HCBS waiver.
3. Maintain, or have access to, information about public and private state and local services, supports and resources and shall make such information available to the Client and/or persons inquiring upon their behalf.
4. Be separate from the delivery of services and supports for the same individual, unless otherwise approved as an exception by the Centers for Medicare and Medicaid services (CMS) in the approved waiver application. Agencies providing HCBS case management services prior to August 30, 2019 shall comply with the timelines set forth at Sections 25.5-10-211.5(3)(f) -(g), C.R.S.
5. Assign one (1) primary person who ensures case management services are provided on behalf of the Client across all programs, professionals within the agency. Reasonable efforts shall be made to include the Client's preference in this assignment.
6. Ensure that services are available on Business Days.
7. Maintain records for seven (7) years after the date a Client discharges from a waiver program, including all documents, records, communications, notes and other materials related to services provided and work performed.
8. Possess appropriate financial management capacity and systems to document and track services and costs in accordance with state and federal requirements.
9. Maintain and update records of persons determined to be eligible for services and supports and who are receiving case management services in accordance with the Departments requirements.
10. Establish and maintain working relationships with community-based resources, supports, and organizations, hospitals, service providers, and other organizations that assist in meeting the Clients' needs.
11. Have a system for recruiting, hiring, evaluating, and terminating employees, and maintain employment policies and practices that comply with federal and state laws.
12. Maintain current written job descriptions for all positions.
13. Maintain a website that at a minimum contains contact information for the agency, the ability for electronic communication, hours of operation, available resources, program options, and services provided.
14. Ensure staff have access to statutes and regulations relevant to the provision of authorized services.
15. Provide case management services for Clients without discrimination on the basis of race, religion, political affiliation, gender, national origin, age, sexual orientation, gender expression or disability.
16. Provide information and reports as required by the Department including, but not limited to, data and records necessary for the Department to conduct operations.
17. Allow access by authorized personnel of the Department, or its contractors, for the purpose of reviewing documents and systems relevant to the provision of case management services and supports funded by the Department and shall cooperate with the Department in the evaluation of such services and supports.
18. If the Case Management Agency is unable to continue providing case management services, the agency must submit a written notice to the Department at least 90 days prior to terminating services. The written notice shall include the effective date of termination.
19. As part of the application process to be an approved Case Management Agency, the agency shall submit a Closeout Plan that describes all requirements, steps, timelines, and milestones necessary to fully transition the services provided by the agency to another Case Management Agency. The Closeout Plan shall designate an individual to act as a closeout coordinator who will ensure that all requirements, steps, timelines, and milestones contained in the Closeout Plan are completed and work with the Department and any other agency to minimize the impact of the transition on Clients and the Department. The Closeout Plan shall include, but is not limited to, all of the following:
a. Notification and communication of agency closure to the Department, Clients and providers;
b. Transfer of Clients;
c. Transfer of documentation to include all electronic and physical documentation;
d. Transfer of all Client records through the Department Case Management System; and
e. Transfer of Case Management Services.
20. Case Management Agencies are responsible for ensuring persons who are employed by the agency meet the requirement of these regulations
21. Maintain verification of Case Managers who are employed meet minimum requirements and qualifications
8.519.4Staffing
8.519.4.A. The case management agency shall provide staff for the following functions: receptionist/clerical, administrative/supervisory, and case management.
1. The receptionist/clerical function shall include, but not be limited to, answering incoming telephone calls, providing information and referral, and assisting case management agency staff with clerical duties.
2. The administrative/supervisory function shall include, but not be limited to, supervision of staff, training and development of agency staff, fiscal management, operational management, quality assurance, case record reviews on at least a sample basis, resource development, marketing liaison with the Department, and, as needed, providing case management services in lieu of the case manager.
8.519.5.Qualifications of Case Managers
8.519.5.A. All Home and Community-Based (HCBS) case managers must be employed by a certified Case Management Agency.
1. CMAs must maintain verification that employed case managers meet the qualifications set forth in these regulations.
8.519.5.B. minimum qualifications for HCBS Case Managers hired on or after October 8th, 2021 are:
1. A bachelor's degree; or
2. Five (5) years of relevant experience in the field of LTSS, which includes Developmental Disabilities; or
3. Some combination of education and relevant experience appropriate to the requirements of the position.
4. Relevant experience is defined as:
a. Experience in one of the following areas: long-term care services and supports, gerontology, physical rehabilitation, disability services, children with special health care needs, behavioral science, special education, public health or nonprofit administration, or health/medical services, including working directly with persons with physical, intellectual or developmental disabilities, mental illness, or other vulnerable populations as appropriate to the position being filled; and,
b. Completed coursework and/or experience related to the type of administrative duties performed by case managers may qualify for up to two (2) years of required relevant experience.
8.519.5.C. Case Managers may not:
1. Be related by blood or marriage to the Client.
2. Be related by blood or marriage to any paid caregiver of the Client.
3. Be financially responsible for the Client.
4. Be the Client's legal guardian, authorized representative, or be empowered to make decisions on the Client's behalf through a power of attorney.
5. Be a provider for the Client, have an interest in, or be employed by a provider for the same Client. Case Managers employed by a Case Management Agency that is operating under an exception approved by the Centers for Medicare and Medicaid Services (CMS) in the approved waiver application are exempt from this requirement.
8.519.5.D. Case Managers must complete the Department prescribed attestation form.
8.519.5.E. Case Managers must complete and document the following trainings within 120 days from the date of hire and prior to providing case management services independently:
1. Department prescribed assessment tool;
2. Service plan development and revision;
3. Referral for services, to include Medicaid and non-Medicaid;
4. Monitoring;
5. Case documentation;
6. Level of Care determination process;
7. Notices and appeals;
8. Incident and critical incident reporting;
9. Waiver requirements and services;
10. Person-centered approaches to planning and practice;
11. Interviewing and assessment skills; and
12. Regulations and state statutes for the LTSS program.
13. Department IMS Documentation
14. Mandatory Reporting
15. Participant Directed Training
16. Disability and Cultural Competency
17. Any Case Management training required by contract
8.519.5.F. Case Managers must demonstrate and document competency in the following areas:
1. Knowledge and experience working with populations served by the Case Management Agency;
2. Knowledge of the statutes, regulations, policies and procedures regarding public assistance programs and the American with Disabilities Act;
3. Knowledge of LTSS and other community resources;
4. Negotiation, conflict resolution, intervention, cultural and linguistic training, disability cultural competency, and interpersonal communication skills; and
5. Knowledge of consumer direction philosophy and programs.
8.519.5.G. Case Managers shall attend any mandatory training required by the Department.
8.519.5.H. Case Manager supervisors shall meet the minimum requirements for education and/or experience for Case Managers and shall have one year of competency in pertinent case management knowledge and skills.
8.519.5.I. Background checks.
1. Prior to employment, all case management staff must have the following minimal background checks and screenings:
a. Criminal;
b. Medicaid or other federal health programs exclusion list;
c. Sex offender registry; and
d. Adult protective services data system.
2. Background checks must be repeated at minimum every five (5) years with the exception of the adult protective services data system.
3. Proof of checks and screenings must be maintained and made available.
8.519.6Repealed
8.519.7Functions of Case Management Agencies for HCBS-CES, HCBS-CHRP, HCBS-DD, and HCBS-SLS
8.519.7.A. Case Management Agencies shall comply with the regulations at Sections 8.500 et seq., 8.503 et seq., 8.600 et seq. and 8.760 et seq.
8.519.7.B. The Case Management Agency chosen by the Client is responsible for providing case management services.
8.519.7.C. Case Management Agencies shall establish agency written procedures sufficient to execute case management services according to the provisions of these regulations. Such procedures shall include, but are not limited to:
1. Comprehensive assessment and periodic reassessment of a Client's needs;
2. Development and periodic revision of Client Service Plans;
3. Referral and related activities;
4. Monitoring;
5. The authorization and purchase of services and supports;
6. Services and support coordination;
7. Any safeguards necessary to prevent conflict of interest between case management and direct services provision; and
8. Denial and discontinuation of services.
8.519.7.D. Case Management Agencies shall have written procedures concerning the exercise and protection of Client rights pursuant to Sections 25.5-10-218 through 231, C.R.S.
8.519.7.E. Case Management Agencies shall have written procedures for Clients to dispute agency decisions, adverse actions, or actions of the agency's employees or contractors. Disputes may be filed by the Client, or parent of a minor Client, the Client's guardian, advocate, or the Client's authorized representative if within the scope of his/her duties. Agency procedures shall meet the requirements of Section 8.605.5. The agency shall offer and provide interpretation or translation services in languages other than English, and through such other modes of communication as may be necessary.
8.519.8Compliance
8.519.8.A. Pursuant to Section 25.5-10-208(4), C.R.S., upon a determination by the executive director or designee that services and supports have not been provided in accordance with the program or financial administration standards contained in these rules, the executive director or designee may reduce, suspend, or withhold payment to a Case Management Agency from which the Department purchases services or supports directly.
8.519.8.B. Prior to initiating action to reduce, suspend, or withhold payment to a Case Management Agency for failure to comply with Department regulations, the executive director or designee shall provide written notice which must specify the reasons for the action and the actions necessary to achieve compliance.
8.519.8.C. The executive director or designees may revoke the Case Management Agency's certification upon a finding that the agency is in violation of provisions of Section 25.5-10-209.5, C.R.S, other state or federal laws, or these rules.
8.519.9Payment for Case Management Services
8.519.9.A. Targeted case management services are only reimbursed for Clients enrolled in the HCBS-CES, HCBS-CHRP, HCBS-DD, HCBS-SLS waivers, and only if the services are in compliance with the requirements set forth at Section 8.760 et seq.
8.519.10Case Management Payment Liability
8.519.10.A. Failure to prepare the service plan and prior authorization or failure to submit the service plan forms in accordance with Department policies and procedures shall result in the denial of reimbursement for services authorized retroactive to first date of service. The Case Management Agency and/or providers may not seek reimbursement for these services from the Client receiving services.
8.519.10.B. If the Case Management Agency causes a Client enrolled in HCBS waiver services to have a break in payment authorization, the agency will ensure that all services continue and will be solely financially responsible for any losses incurred by service providers until payment authorization is reinstated.
8.519.11Case Management Services
8.519.11.A. Clients must be determined eligible for an HCBS waiver specific for individuals with Intellectual or Developmental Disabilities by a Community Centered Board prior to receiving case management services.
8.519.11.B. Case management services include the following:
1. Assessment: comprehensive assessment and periodic reassessment of individual needs to determine the need for any medical, educational, social or other services and completed annually or when the Client experiences significant change in need or in level of support. Assessment activities include:
a. Obtaining Client history;
b. Identifying the Client's needs, completing related documentation, and gathering information from other sources such as family members, medical providers, social workers and educators, as necessary to form a complete assessment of the Client.
2. Service plan development and revision occurs no less than annually or as a warranted by the Client's needs or change in condition, at a time and location convenient for the Client with the Client and others chosen by the Client. The Case Manager shall complete and review a service plan for each Client enrolled in the HCBS-CES, HCBS-DD, and HCBS-SLS waivers.
a. The service plan at minimum shall:
i. Identify needs, personal goals, preferences, unique strengths, abilities, desires, health and safety, and risk factors;
ii. Be in accordance with the Department's regulations, policies and procedures;
iii. Identify the specific services and supports appropriate to meet the needs of the eligible Client, and family, as applicable;
iv. Document decisions made through the service planning process including, but not limited to, rights suspension/modifications, the existence of appropriate services and supports and the actions necessary for the plan to be achieved;
v. Document the authorized services and supports funded by the Department and the date authorized services begin or the projected date of initiation;
vi. Identify a contingency plan for how necessary supports will be provided in the event that the Client's family, caregiver, or direct HCBS waiver provider is unavailable due to an emergency situation or unforeseen circumstances;
vii. Have a listing of the service plan participants and their relationship to the Client;
viii. Contain a statement of agreement with the plan signed, physical or digital signature, by the Client or other such person legally authorized to sign on the Client's behalf; and
ix. Be in effect for a period not to exceed one year without review and be reviewed and amended as determined by the Case Manager, Client, and others as applicable.
b. The service plan shall document that the Client has been offered a choice:
i. In the Home and Community-based Services or institutional care,
ii. Of waiver services, including service delivery options, and
iii. Of qualified providers.
c. The service plan shall contain documentation that the Client is aware of the conflict of interest in situations where the Case Management Agency is the only agency able to provide direct HCBS waiver services, as approved in the waiver application, and that the Client has been provided a complaint and grievance procedure.
d. The service plan development shall occur at times and locations chosen by the Client to include but not limited to the Client's place of residence, place of service, or other appropriate setting as determined by the Client's needs or preferences.
e. Others chosen by the Client shall be provided notification at least ten (10) days prior to the service plan meeting, if possible.
f. Copies of the service plan shall be disseminated to all persons and providers involved in implementing the service plan including the Client, their legal guardian, authorized representative and parent(s) of a minor, and others as applicable. If requested, copies shall be made available prior to the provision of services or supports, or within a reasonable period of time not to exceed thirty (30) days from the development of the service plan and in accordance with these rules;
3. Referral: the Case Manager shall assist Clients to obtain needed HCBS waiver services or other programs and services, to include non-Medicaid services, which include making referrals to providers, scheduling appointments, and assisting with access to transportation as needed or requested by the Client.
4. Monitoring: the Case Manager shall ensure that Clients receive services in accordance with their Service Plan and monitor the quality of the services and supports provided to the Clients.
a. The frequency and level of monitoring shall meet the requirements of the waiver in which the Client is enrolled. At a minimum, monitoring shall occur at least once per quarter, face-to-face, in a place where services are delivered, and review the following for each Client:
i. The delivery and quality of services and supports identified in the service plan including ensuring that services are delivered in accordance with the scope, frequency, and duration documented in the service plan;
ii. The health, safety and welfare of Clients, including the provider agencies' procedures to address the Client's needs;
iii. The satisfaction with services and choice in providers;
iv. Services are being delivered in a way that promote a Client's ability to engage in self-determination, self- representation and self-advocacy;
v. Concerns or issues as they relate to provider agencies. The Case Manager shall contact the provider agency to coordinate, arrange, or adjust services to address and resolve quality issues or concerns;
vi. The case manager shall immediately report, to the appropriate agency, any information which indicates an overpayment, incorrect payment or misutilization of any public assistance benefit and shall cooperate with the appropriate agency in any subsequent recovery process.
b. Upon Department approval, monitoring 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.).
5. Remediation: the Case Manager shall identify and implement strategies to prevent and resolve problems with the delivery of services and supports.
8.519.12Case Documentation
8.519.12.A. The Case Management Agency shall complete and maintain all required records in the state approved IMS and shall maintain individual case records at the agency level for any additional documents associated with the individual enrolled in a HCBS waiver.
1. The case records shall include:
a. Identifying information, including the Client's state identification (Medicaid) number, date of birth (DOB) social security number (SSN), address and phone number;
b. Department required forms specific to the program in which the Client is enrolled; and
c. Documentation of all case management activity.
2. Case management documentation shall meet all of the following standards:
a. Be objective and understandable;
b. Occur at the time of the activity or no later than five (5) business days from the time of the activity;
c. Dated according to the date of the activity, including the year;
d. Entered into the Department's IMS;
e. Identify the person creating the documentation;
f. Entries must be concise and include all pertinent information;
g. Information must be kept together, in a logical organized sequence, for easy access and review;
h. The source of all information shall be recorded, and the record shall clarify whether information is observable and objective fact or is a someone's judgement or conclusion;
i. All persons and agencies referenced in the documentation must be identified by name and by relationship to the individual;
j. All forms prescribed by the Department shall be completely and accurately filled out by the Case Manager; and,
k. If the Case Manager is unable to comply with any of the regulations specifying the time frames within which case management activities are to be completed, due to circumstances outside the case management agency's control, the circumstances shall be documented in the case record.
3. These circumstances shall be taken into consideration when monitoring the Case Management Agency's performance.
8.519.13Choice of provider agency for authorized HCBS waiver services
8.519.13.A. Clients and/or their guardians and authorized representatives, as appropriate, who enroll in HCBS waiver services shall have the freedom to choose from qualified provider agencies in accordance with Section 8.603, as applicable.
8.519.13.B. Case Management Agencies shall provide Clients, and/or their guardian, and authorized representatives, as appropriate, informed choice on all provider agencies qualified to provide the authorized HCBS waiver services.
1. When the Client or guardian, or authorized representative when applicable, knows which qualified provider agency(ies) they want to provide the authorized HCBS waiver service(s), the Client shall inform the Case Manager of their choice.
a. The Case Manager shall contact the selected provider agency(ies) regarding the Client's needs, the services authorized, and the scope, frequency, and duration of services.
b. If the provider agency(ies) are willing to provide the authorized HCBS waiver service(s), the Case Manager shall create the Prior Authorization Request in accordance with Section 8.519.14.
c. If the provider agency(ies) are not willing to provide the authorized HCBS waiver service(s), the Case Manager shall inform the Client and discuss options for additional provider selection as outlined in Section 8.519.13.B(2).
2. If the Client or guardian (as appropriate) does not know which provider agency(ies) the Client wants to select, the Case Manager shall provide informed choice to the Client which may include, but is not limited to:
a. Providing a list of qualified provider agencies;
b. Providing the Department's webpage address and information on how to search for a qualified provider agency;
c. Providing resources for accessing information about provider agency quality, such as survey information, that is available to the public;
d. Providing information regarding qualified provider agencies based on the Client's preferences;
e. Contacting all qualified provider agencies, with information regarding the requested and authorized service(s) including the scope, frequency, level of support necessary, and duration of the services for the purpose of receiving responses from qualified service agencies who can serve the Client to not include Support Level information unless requested by the Client family and/or guardian; or
f. In addition to other assistance as requested or needed by the Client.
3. The case manager shall document the Client's choice of provider agency(ies) and the method by which the choice was made in the Service Plan and in the Department's prescribed system.
4. Case Managers shall contact all requested providers within five (5) business days of the Client's selection.
8.519.14Prior Authorization Requests (PAR)
8.519.14.A. The Case Manager shall submit a PAR in compliance with all applicable regulations and ensure requested services are:
1. Consistent with the Client's documented medical condition and needs assessment;
2. Adequate in amount, frequency, scope and duration in order to meet the Client's needs and within the limitations set forth in the current federally approved waiver; and
3. Not duplicative of another service, including but not limited to services provided through:
a. Medicaid state plan benefits,
b. Third party resources,
c. Natural supports,
d. Charitable organizations, or
e. Other public assistance programs.
4. Services delivered without prior authorization shall not be reimbursed except for provision of services during an emergency pursuant to Section 8.058.4.
8.519.15Regional Center Referral Process
8.519.15.A. Referrals to the Regional Centers shall comply with the Regional Centers admission policy located on the Colorado Department of Human Services website.
8.519.16Critical Incident Reporting
8.519.16.A. Case Management Agencies shall have a written policy and procedure for the recording, reviewing, and reporting of critical incidents. Critical incident reporting is required when the following occurs:
1. Injury/Illness;
2. Missing Person;
3. Criminal Activity;
4. Unsafe Housing/Displacement;
5. Death;
6. Medication Management Issues;
7. Other High Risk Issues;
8. Allegations of abuse, mistreatment, neglect, or exploitation;
9. Damage to Consumer's Property/Theft.
8.519.16.B. Allegations of abuse, mistreatment, neglect and exploitation, and injuries which require emergency medical treatment or result in hospitalization or death shall be reported immediately to the agency administrator or designee, Case Management Agency, and to the CCB
1. Case Managers shall comply with mandatory reporting requirements set forth at Section 18-6.5-108, C.R.S, Section 19-3-304, C.R.S and Section 26-3.1-102, C.R.S.
8.519.16.C. Case Managers shall report critical incidents in the State-Approved IMS within 24 hours of notification. Each report must include:
a. Incident type
i. Mistreatment, Abuse, Neglect or Exploitation (MANE) as defined at Section 19-1-103, C.R.S, Section 26-3.1-101, C.R.S, Section 16-22-102(9) C.R.S, and Section 25.5-10-202 C.R.S.
ii. Non-Mane: A Critical Incident, including but not limited to, a category of criminal activity, damage to a consumer's property, theft, death, injury, illness, medication management issues, missing persons, unsafe housing or displacement, other high-risk issues.
b. Date and time of incident;
c. Location of incident, including name of facility, if applicable;
d. Individuals involved.
e. Description of incident, and
f. Resolution of incident, if applicable.
g. Case Manager shall complete required follow up activities and reporting in the State approved IMS within assigned timelines.
8.519.16.D. Incident reports submitted to by a provider to the CCB or, Case Management Agency will be reviewed by the case manager, documented into the state IMS and entered as a critical incident if the incident meets critical incident reporting criteria. Incident reports are to be made available to the Department upon request.
8.519.17Client Responsibilities
8.519.17.A. A Client, when provided with appropriate and necessary accommodations, or guardian is responsible to:
1. Provide accurate information regarding the Client's ability to complete activities of daily living;
2. Assist in promoting the Client's independence;
3. Cooperate in the determination of financial eligibility for Medicaid;
4. Notify the Case Manager within thirty (30) days after:
a. Changes in the Client's support system, medical, physical or psychological condition, or living situation including any hospitalizations, emergency room admissions, placement in a nursing home or Intermediate Care Facility for Individuals with Intellectual Disability (ICF-IID)
b. The Client has not received an HCBS waiver service during one (1) calendar month;
c. Changes in the Client's care needs;
d. Problems with receiving HCBS waiver services for which the Client would like the Case Manager's assistance to resolve; and
e. Changes that may affect Medicaid financial eligibility, including promptly reporting changes in income or assets;
f. Client will notify the Case Manager when withdrawing from services.
5. Cooperate with Case Management Agency requirements for the functions of case management outlined in Section 8.519 et seq.
8.519.18Use of an Authorized Representative
8.519.18.A. Clients who are eligible for services and supports, the parent or guardian of a minor, or legal guardian of an adult, shall be informed at the time of enrollment and at each annual review of the service plan that they may designate an authorized representative. The designation of an authorized representative must occur with informed consent of the Client, or the parent or guardian of a minor, or legal guardian of an adult.
8.519.18.B. A designation of an authorized representative shall be in writing and specify the extent of the authorized representative's involvement in assisting the Client receiving services, in acquiring or utilizing services or supports available, and in safeguarding the Client's rights.
8.519.18.C. The written designation of an authorized representative shall be maintained in the Client's record and shall be reviewed annually.
8.519.18.D. The Client may withdraw their designation of an authorized representative at any time and must notify the Case Manager of the withdrawal.
8.519.19Petitions for Declaratory Orders
8.519.19.A. Disposition of petitions for declaratory orders
1. The executive director of the Department or designee may entertain petitions for declaratory orders in accordance with Section 24-4-105(11), C.R.S., when a controversy or uncertainty exists as to the applicability of any statutory or regulation of the Department to a party. A petition may be filled when a process for resolving the controversy or uncertainty is not otherwise provided in these rules.
8.519.19.B. Any petition filled pursuant to this rule shall set forth the following:
1. The name and address of the petitioner;
2. The statute, rule or order to which the petition relates;
3. A concise statement of all of the facts necessary to show the nature of the controversy of uncertainty; and.
4. All parties directly involved in the subject matter of the petition known to the petitioner.
8.519.19.C. If the executive director or designee decides to rule on the petition, the following procedure shall apply:
1. The executive director or designee shall provide notice of the petition and an opportunity to respond to the petition to all parties noted by the petitioner or otherwise known to the Department to be directly interested in the petition.
2. The executive director or designee may rule upon the petition based solely upon the facts presented in the petition and response. In such a case any ruling of the Department will apply only to the extent of the facts presented in the petition and the response.
3. The executive director or designee may request the petitioner or any involved party to submit additional information, or file a written brief, memorandum, or statement of position.
4. The executive director or designee may rule upon the petition without a hearing or may set the petition for hearing, upon due notice to all parties to obtain additional facts or information.
5. The ruling of the Department shall be Final Agency Action subject to judicial review.
8.519.20Grievance/Complaint process
8.519.20.A. Case Management Agencies shall have procedures setting forth a process for the timely resolution of grievances or complaints. Use of the grievance procedure shall not prejudice the future provision of appropriate services or supports.
8.519.20.B. The grievance procedure shall be provided, orally and in writing, to all Clients receiving services, the parents of a minor, guardian and/or authorized representative, as applicable, at the time of submission and at any time that changes to the procedure occur.
8.519.20.C. The grievance procedure shall, at a minimum, including the following:
1. Contact information for a person within the CMA who will receive grievances.
2. Identification of support person(s) who can assist the Client in submitting a grievance.
3. An opportunity to find a mutually acceptable solution. This could include the use of mediation if both parties voluntarily agree.
4. Timelines for resolving the grievance.
5. Consideration by the agency director or designee if the grievance cannot be resolved at a lower level.
6. Assurances that no Client shall be coerced, intimidated, threatened or retaliated against because the Client has exercised his or her right to file a grievance or has participated in the grievance process.
8.519.21Termination from services and supports
8.519.21.A. A Client shall be terminated from services and supports if the CCB or Case Management Agency determines that the Client no longer meets the eligibility criteria.
8.519.21.B. A Client shall be discontinued from a service or support upon determination, made pursuant to the service planning process, that the services or supports are no longer appropriate or necessary to meet the Client's needs.
8.519.21.C. A Client receiving services may notify a service agency, verbally or in writing, that he or she no longer wishes to receive services from the provider agency. If the Client is a minor, has a legal guardian, authorized representative or is under court jurisdiction, the Client's parent(s), guardian or authorized representative shall be notified immediately after the Client notifies the service agency of the desire to discontinue services. The parent(s) of a minor or legal guardian shall be provided the option to exercise their decision-making authority on behalf of the Client receiving service, unless otherwise ordered by a court.
8.519.22Notice and Appeal Rights
8.519.22.A. The Case Management Agency shall provide the long-term care notice of action form to Clients within eleven (11) business days regarding their appeal rights in accordance with Section 8.057 et seq, when:
1. An adverse action occurs that affects the provision of the Client's waiver services, or:
8.519.22.B. The Case Management Agency shall notify all providers in the Client's service plan within one (1) business day of the adverse action.
1. The Case Management Agency shall notify the county Department of Human/Social services income maintenance technician within ten (10) business days of an adverse action that may affect financial eligibility for HCBS waiver services.
8.519.22.C. The applicant or Client shall be provided a notice of adverse action if the applicant or Client is determined to be ineligible as set forth in the waiver specific Client eligibility criteria and the following:
1. The Client cannot be served safely within the cost containment as identified in the HCBS waiver;
2. The Client is placed in an institution for treatment for more than thirty (30) consecutive days;
3. The Client is detained or resides in a correctional facility; or
4. The Client enters an institute for mental health for more than thirty (30) consecutive days.
8.519.22.D. The Client shall be notified, pursuant to Section 8.057.2.A., when the following results in an adverse action that does not relate to waiver Client eligibility requirements:
1. A waiver service is reduced, terminated or denied because it is not a demonstrated need in the needs assessment;
2. A service plan or waiver service exceeds the limits set forth in the federally approved waiver;
3. The Client is being terminated from HCBS due to a failure to attend a Level of Care assessment appointment after three (3) attempts to schedule by the Case Manager within a thirty (30) day consecutive period.
4. The Client is being terminated from HCBS due to a failure to attend a Service Plan appointment after three (3) attempts to schedule by the Case Manager within a thirty (30) day consecutive period.
5. The Client enrolls in a different LTSS program, or
6. Benefits are terminated because the Client moves out of state.
A. A Client who leaves the state on a temporary basis, with intent to return to Colorado, pursuant to Section 8.100.3.B.4, shall not be terminated unless one or more of the other Client eligibility criteria are no longer met.
7. The Client voluntarily withdraws from the waiver. The Client shall be terminated from the waiver effective upon the day after the date on which the Client's request is documented.
A. The Case Manager shall review with the Client their decision to voluntarily withdraw from the waiver. The Case Manager shall not send a notice of action, upon confirmation of withdraw.
8.519.22.E. The case management agency shall not send the LTC notice of action form when the basis for termination is death of the Client, but shall document the event in the Client record. The date of action shall be the day after the date of death.
8.519.22.F. The case management agency shall appear and defend their decision at the Office of Administrative Courts when the case management agency has made a denial or adverse action against a Client.
1. When the Office of Administrative Courts rules in favor of the appellant, the Case Management Agency shall file exceptions when appropriate.
8.519.23Retrospective review process
8.519.23.A. Services provided to a Client are subject to a retrospective review which includes but is not limited to a performance and quality review by the Department. The retrospective review shall ensure that services:
1. Identified in the service plan are based on the Client's assessed needs;
2. Have been requested and approved prior to the delivery of services;
3. Provided to a Client are in accordance with the service plan, and;
4. Provided within the specified HCBS waiver service definition in the federally approved HCBS waiver.
8.519.23.B. When the retrospective review identifies areas of noncompliance, the case management agency shall be required to submit a corrective action plan that is monitored for completion by the Department.
8.519;23.C. The inability of the case management agency to implement a plan of correction within the timeframes identified in the plan of correction may result in temporary suspension of claims payment or termination of the provider agreement.
8.519.23.D. When the provider has received reimbursement for services and the review by the Department identifies that it is not in compliance with requirements, the amount identified is subject to recovery pursuant to Section 8.076.
8.519.27Transition Coordination Services
8.519.27.ADefinitions
1. Case Management Agency (CMA) 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 § 25.5-10-209.5, C.R.S. and pursuant to a provider participation agreement with the Department.
2. Community Needs and Preferences Assessment means the assessment that is completed by the Transition Options Team to ensure a comprehensive understanding of the member's health conditions, functional needs, transition needs, behavioral concerns, social and cultural considerations, educational interests, risks, and other areas that may require services and/or community resource support.
3. Community risk level means the potential for a member living in a community-based arrangement to require emergency services; to be admitted to a hospital, skilled nursing facility, or Intermediate Care Facility for Individuals with Intellectual Disabilities; to be evicted from their home; or to be involved with law enforcement due to identified risk factors.
4. Corrective Action Plan means a written plan by the Transition Coordination Agency, and approved by the Department, which includes a detailed description of actions to be taken to correct non-compliance with regulations, and/or direction from the Department, and which sets forth the date by which each action shall be completed and the persons responsible for implementing the action. Corrective Action Plans may be requested by the Department at any time.
5. Post-transition monitoring means the activities performed by a Transition Coordination Agency (TCA) that occur after a member has successfully transitioned into the community and is a recipient of home-and community-based services.
6. Pre-transition coordination means the activities by the TCA that occur before a member has transitioned into the community to prepare the member for success in community living and integration.
7. Risk factors means factors that include, but are not limited to, health, safety, environmental, community integration, service interruption, inadequate support systems, and substance abuse that may contribute to an individual's community risk level.
8. Risk mitigation plan means the document that records the risk mitigation planning process. Risk mitigation plans are used to complete pre-transition strategy development, conduct post-discharge monitoring of effectiveness of risk prevention strategies, document identification of additional risk factors, and revise risk incident response plans.
9. Risk mitigation planning means the process of identifying risk factors, developing options and actions to enhance opportunities and prevent adverse consequences that would result if risk is not managed. Risk mitigation planning includes identifying planned actions to take in response to an adverse consequence should a risk be realized.
10. Transition assessment means the process of capturing a comprehensive understanding of the member's health conditions, functional needs, transition needs, behavioral concerns, social and cultural considerations, educational interests, risks, and other areas important to community integration and transition to a home and community-based setting.
11. Transition coordination services means support provided to a member who is transitioning from a skilled nursing facility, extended SNF LOC hospital stay, Intermediate Care Facility for Individuals with Intellectual Disabilities, or regional center and includes the following activities: comprehensive assessment for transition, community risk assessment, development of a transition plan, referral and related activities, and monitoring and follow up activities as they relate to the transition.
12. Transition Coordinator (TC) means a person who provides transition coordination services and meets all regulatory requirements for a TC.
13. Transition Coordination Agency (TCA) means a public or private not-for-profit or for-profit agency that meets all applicable state and federal requirements and is certified by the Department to provide transition coordination pursuant to a provider participation agreement with the Department.
14. Transition Options Team (TOT) means the group of people involved in supporting and implementing the transition. The TOT includes the person receiving services, the TC, and the guardian. The TOT may include the home- and community- based services case manager, nursing facility social worker and others chosen by the individual receiving services as being valuable to participate in the transition process. The TOT works in a cooperative and supportive manner to develop and implement the transition plan and to serve in an advocacy role with the member.
15. Transition period means the period of time in which the member receives transition coordination services for the purpose of successful integration into community living. A transition period is complete when the member has successfully established community residence and is no longer in need of transition coordination services based on the member's community risk level, or the member or guardian requests that TCM-TC services are discontinued.
16. Transition plan means the written document that identifies person-centered goals, assessed needs, and the choices and preferences of services and supports to address the identified goals and needs; appropriate services and additional community supports; outlines the process and identifies responsibilities of Transition Options Team members; details a risk mitigation plan; and establishes a timeline that will support an individual in transitioning to a community setting of their choosing.
17. Transition planning means the completion of the TCM-TC community needs and preferences assessment and risk mitigation plan, facilitation of a transition recommendation, and developing a transition plan, in coordination with the Transition Options Team.
18. Transition recommendation means a recommendation made by the transition options team regarding transition. The recommendation is made solely on availability of necessary supports and services identified by the community needs and preference assessment and the risk mitigation plan.
8.519.27.BQualifications of Transition Coordination Agencies
1. In order to be approved as a TCA, the agency shall meet all of the following qualifications:
a. Have a physical location in Colorado.
b. Be a public or private not-for-profit or for-profit agency.
c. Demonstrate proof the agency has employed staff that meet TC qualifications.
d. Have a minimum of two years of agency experience in assisting at-risk individuals with accessing medical, social, education and/or other services. TCAs providing transition coordination in Colorado prior to December 31, 2018 are exempt from this requirement.
e. Provide transition coordination services to members who select the agency and also reside in the county/counties for which the agency has elected to provide services.
f. Possess the administrative capacity to deliver transition coordination.
g. Have established community referral systems and demonstrate ability to make community referrals for services with other agencies.
h. Demonstrate ability to meet all applicable requirements contained within Section 8.519.27, Section 8.763, the Medicaid State Plan, and the provider participation agreement.
i. Financial reserves shall match one month of expenditures associated to the number of members expected through that catchment area and provide stability for TCs, members and service providers. All agencies are required to submit an audited financial statement or equivalent to the Department for review upon request.
j. Possess and maintain adequate liability insurance (including automobile insurance, professional liability insurance, and general liability insurance) to meet the Department's minimum requirements.
8.519.27.CFunctions of all Transition Coordination Agencies
1. In order to be approved as a TCA, the agency shall perform all of the following functions:
a. TCAs must be in compliance with all required agency performance standards and training guidelines to be in good standing with the Department. Failure to comply with required standards and training guidelines may result in suspension of referrals until a Corrective Action Plan is submitted by the TCA and approved by the Department.
b. TCAs shall be responsible for maintaining sufficient documentation, as defined in TCM-TC training, of all transition coordination activities performed and to support claims within the Department-designated data system and internal agency records.
c. TCAs may not provide guardianship services for any member for whom they provide transition coordination services.
d. TCAs shall be responsible for maintaining, or having access to, information about public and private, state and local services, supports and resources and shall make information available to the member and/or persons inquiring upon their behalf.
e. TCAs shall respond to referrals for transition coordination support within two business days and specify whether the referral is accepted or not by completing the Transition Services Referral Form.
f. TCAs shall assign and meet with the member within 10 state business days after accepting a referral.
g. TCAs shall assign one primary person who ensures transition coordination is provided to the member.
h. TCAs shall provide coordination in accordance with state business days as defined in § 24-11-101(1), C.R.S.
i. TCAs shall maintain all documents, records, communications, notes, and other materials that relate to any work performed.
j. TCAs shall possess appropriate financial management capacity and systems to document and track services and costs in accordance with state and federal regulations.
k. TCAs shall maintain and update records of persons receiving transition coordination in accordance with reporting requirements of the Department's data system.
l. TCAs shall establish and maintain working relationships with community- based resources, supports, and organizations, hospitals, service providers, and other organizations that assist in meeting the needs of members.
m. TCAs shall have a system for recruiting, hiring, evaluating, and terminating employees. Transition coordination agencies' employment policies and practices shall comply with all federal and state laws.
n. TCAs shall ensure staff have access to statutes and regulations relevant to the provision of authorized services and shall ensure that appropriate employees are oriented to the content of statutes and regulations.
o. TCAs shall provide transition coordination for members without discrimination on the basis of race, religion, political affiliation, gender, national origin, age, sexual orientation, gender expression, or disability.
p. TCAs shall provide information and reports as required by the Department including, but not limited to, data and records necessary for the Department to conduct operations.
q. TCAs shall allow access by authorized personnel of the Department, or its contractors, for the purpose of reviewing services and supports funded by the Department and shall cooperate with the Department in evaluation of such services and supports.
r. TCAs shall establish agency procedures sufficient to execute transition coordination according to the provisions of these regulations. Such procedures shall include, but are not limited to:
i. Referral management;
ii. Assessment of community needs and preferences;
iii. Transition planning;
iv. Risk mitigation planning;
v. Service and support coordination for non-Medicaid transition-related services and supports;
vi. Monitoring of the transition and transition plan review;
vii. Denial and discontinuation of transition coordination services;
viii. Management of interstate TCM-TC transfers; and
ix. Complaint procedure that includes the requirement to share information, such as points of contact within the agency, to members, families and referring agencies who may wish to file a complaint.
8.519.27.DQualifications of Transition Coordinators
1. TCs must be employed by an approved TCA. TC minimum experience:
a. A bachelor's degree; or
b. Five years of relevant experience in the field of LTSS, which includes Developmental Disabilities; or
c. Some combination of education and relevant experience appropriate to the requirements of the position.
d. Relevant experience is defined as:
i. Experience in one of the following areas: long-term care services and supports; gerontology; physical rehabilitation; disability services; children with special health care needs; behavioral science; special education; public health or nonprofit administration; or health/medical services, including working directly with persons with physical, intellectual or developmental disabilities, mental illness, or other vulnerable populations as appropriate to the position being filled; and,
ii. Completed coursework and/or experience related to the type of administrative duties performed by case managers may qualify for up to two years of required relevant experience.
iii. For members for whom the TC is providing transition coordination, TCs may not:
1) Be related by blood or marriage to the member.
2) Be related by blood or marriage to any paid caregiver of the member.
3) Be financially responsible for the member.
4) Be the member's legal guardian, authorized representative, or be empowered to make decisions on the member's behalf through a power of attorney.
8.519.27.ETraining
1. TCs must complete and document the following trainings within 90 days from the date of hire and prior to providing transition coordination services independently, and thereafter on an annual basis:
a. Assessment of community needs/preferences and risk factors;
b. Transition planning;
c. Risk mitigation plan development, monitoring and revision;
d. Referral for non-Medicaid services;
e. Monitoring services;
f. Case documentation;
g. Person-centered approaches to planning and practice; and
h. Housing voucher application and housing navigation services
8.519.27.FFunctions of Transition Coordinators
1. TCs shall perform each of the following activities when providing Transition Coordination Services. These activities are the only activities billable under transition coordination:
a. Coordinate Transition Options Team (TOT) activities including:
i. Facilitate completion of an assessment which identifies preferences, needs and any risk factors the member may have in a community-based setting within six weeks of first meeting with the member.
ii. Facilitate development of a risk mitigation plan to address identified risk factors within eight weeks of accepting a referral.
iii. Identify supports and services that will be required to address the member's needs, preferences, and risk factors.
iv. Solidify a transition recommendation from the TOT within six weeks of first meeting with the member but not before the first TOT meeting.
v. Facilitate completion of a transition plan if the member chooses to proceed with the transition.
b. Conduct pre-transition coordination including:
i. Facilitate completion of transition assessment, risk mitigation, and transition plans.
ii. Complete, as needed, housing voucher application, including assistance to obtain necessary documents.
iii. Collaborate, as needed, with housing navigation services to obtain a voucher and locate housing.
iv. Assist member to create a transition budget.
v. Collaborate with housing navigation services, Division of Housing, voucher administrators, and property managers to establish a community-based living arrangement.
vi. Coordinate any medication, home modification, and/or durable medical equipment needs with the nursing facility or HCBS case manager prior to discharge to ensure that all components of the transition plan are in place prior to discharge.
vii. Assist member in preparing for discharge, including being present at the nursing facility on the day of discharge to ensure requirements of discharge plan are addressed.
viii. Meet with the member at their home on the day of discharge to ensure that providers and services needed upon discharge are in place and the household set-up is complete.
c. Conduct post-transition monitoring that meets the member's need as documented in the risk mitigation plan and occurs at the frequency and type to meet the member's community risk level. Post-transition monitoring includes:
i. Ensuring that members receive services in accordance with their transition plan and risk mitigation plan.
ii. Provision of support services to aid in sustaining community-based living
iii. Response to risk incidents and notifying the CMA and Adult Protection Services (APS) as required.
iv. Revision of risk mitigation plan as needed.
v. Assessing the need for independent living skills training.
vi. Problem-solving community integration issues.
vii. Supporting community integration activities
viii. Monitoring service provision, to include contacting guardians, providers, and case management agencies.
ix. Requesting that member completes a TCM-TC satisfaction survey prior to discharge and at the end of the transition period to evaluate the member's experience of the following:
1) Transition planning.
2) Transition plan implementation.
3) Transition coordination process.
4) Level and adequacy of services provided.
5) Overall member satisfaction.
d. Post-transition monitoring may include as determined by the community risk level:
i. Face-to-face in the member's residence.
ii. Face-to- face in the community.
iii. Telephone, electronic, video or virtual communication.
2. Post-transition monitoring may not duplicate services for Life Skills Training (LST), defined in 10 C.C.R. 2505-10, § 8.553.3; Transition Setup defined in 10 C.C.R. 2505-10, § 8.553.4; Home Delivered Meals, defined in 10 C.C.R. 2505-10, § 8.553.5; and Peer Mentorship, defined in 10 C.C.R. 2505-10, § 8.553.6.
8.519.27.GTransition Coordination Agencies Approval
1. A TCA shall maintain Department provider approval in accordance with quality assurance standards and requirements set forth in the Department's rules and direction. Department approval is needed for continued receipt of TCM-TC referrals.
a. Approval as a TCA shall be based on an evaluation of the agency's performance in the following areas:
i. The frequency of requests for TCA changes and/or complaints received by the Department pertaining to agency performance;
ii. The agency's compliance with program requirements, including compliance with transition coordination standards adopted by the Department;
iii. The agency's performance of administrative functions, including, timely reporting, program management, on-site visits to individuals, community coordination and outreach and individual monitoring;
iv. Financial accountability;
v. The maintenance of qualified and trained personnel to perform transition coordination duties;
vi. Continual performance and quality assurance activities; and
vii. Overall member satisfaction as indicated by member satisfaction surveys.
2. The Department or its designee shall conduct reviews of the TCA.

At least 60 days prior to expiration of the previous approval date the Department shall notify the TCA of the outcome of the review, which may be approval, provisional approval, or denial of approval.

8.519.27.HConflict of Interest for Transition Coordination Agencies
1. If a TCA also provides services under HCBS waivers, a policy must be in place to avoid conflicts of interest and provide a free choice of providers to members. The HCBS case management agency shall be responsible for all service brokering for Medicaid HCBS services.

10 CCR 2505-10-8.519

46 CR 13, July 10, 2023, effective 7/30/2023
47 CR 05, March 10, 2024, effective 3/30/2024