10 Colo. Code Regs. § 2505-10-8.7100

Current through Register Vol. 47, No. 24, December 25, 2024

Section 10 CCR 2505-10-8.7100 - Waiver/Program Eligibility Requirements

8.7100.ADefinitions:

Unless otherwise specified, the following definitions apply throughout Section 8.7000-8.7500.

1. Activities of Daily Living means basic self-care activities including bathing, bowel and bladder control, dressing, eating, independent ambulation, and needing supervision to support behavior, medical needs, and memory and cognition.

2. Agency means any public or private entity operating in a for-profit or nonprofit capacity, with a defined administrative and organizational structure. At Health Care Policy and Financing's discretion, any sub-unit of the Agency that is not geographically close enough to share administration and supervision on a frequent and adequate basis shall be considered a separate Agency for purposes of certification and contracts.

3. Applicant means an individual or Member who is seeking a Long-Term Services and Supports eligibility determination and who has not affirmatively declined to apply for Medicaid or participate in an Assessment.

4. Assessment is as defined at Section 8.7200.B.1

5. BBA Working Disabled Group is as defined at 42 U.S.C § 1396a(a)(10)(A)(ii) (XIII)).

6. Brain Injury means an injury to the brain of traumatic or acquired origin that results in residual physical, cognitive, emotional, and behavioral difficulties of a non-progressive nature and is limited to the following broad diagnoses found within the most current version of the International Classification of Diseases (ICD) at the time of Assessment:

a. Nonpsychotic mental disorders due to brain damage; or

b. Anoxic brain damage; or

c. Compression of the brain; or

d. Toxic encephalopathy; or

e. Subarachnoid and/or intracerebral hemorrhage; or

f. Occlusion and stenosis of precerebral arteries; or

g. Acute, but ill-defined cerebrovascular disease; or

h. Other and ill-defined cerebrovascular disease; or

i. Late effects of cerebrovascular disease; or

j. Fracture of the skull or face; or

k. Concussion resulting in an ongoing need for assistance with Activities of Daily Living; or

l. Cerebral laceration and contusion; or

m. Subarachnoid, subdural, and extradural hemorrhage, following injury; or

n. Other unspecified intracranial hemorrhage following injury; or

o. Intracranial injury; or

p. Late effects of musculoskeletal and connective tissue injuries; or

q. Late effects of injuries to the nervous system; or

r. Unspecified injuries to the head resulting in an ongoing need for assistance with Activities of Daily Living.

7. Case Management is as defined at Section 25.5-6-1701 C.R.S including the calculation of Member payment.

8. 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 (HCBS) waivers.

9. Member is as defined in 8.7001.A.8-B.

10. Complex Behavior means behavior that occurs related to a diagnosis by a licensed physician, psychiatrist, or psychologist that includes one or more substantial disorders of the cognitive, volitional, or emotional process that grossly impairs judgment or capacity to recognize reality or to control behavior.

11. Complex Medical Needs means needs that occur as a result of a chronic medical condition diagnosed by a licensed physician that has lasted or is expected to last at least twelve (12) months, requires skilled care, and that without intervention may result in a severely life-altering condition.

12. Congregate Facility means a residential facility that provides room and board to three or more adults who are not related to the owner and who, because of impaired capacity for independent living, elect protective oversight, personal services, and social care but do not require regular twenty-four hour medical or nursing care.

13. Uncertified Congregate Facility means a facility as defined at Section 8.7100.A.12 that is not certified as an Alternative Care Facility.

14. Continued Stay Review means a re-assessment conducted by a Case Management Agency as defined in Section 8.7202.F.

15. Comprehensive Review of the Person's Life Situation means a thorough review of all aspects of the person's current life situation by the Provider Agency in conjunction with other Members of the Member Identified Team.

16. Corrective Action Plan is as defined at Section 8.7200.B.11

17. Cost Containment means the same as Provisions for Compliance with Federal Cost Effectiveness at 8.7100.A.52-A.

18. Crisis means an event, series of events, and/or state of being of greater than normal severity for the Member and/or Family that is outside the manageable range for the Member or their Family and poses a danger to self, family, and/or the community. Crisis may be self-identified, family-identified, and/or identified by an outside party.

19. Deinstitutionalized means transferred from institutional care to community-based care.

20. Diverted means maintained in institutional care.

21. Developmental Delay means one or more of the following:

a. A child less than five years of age who is at risk of having a Developmental Disability because of the presence of one or more of the following measurements as determined by a qualified health professional utilizing appropriate diagnostic methods and procedures:

i. Chromosomal conditions associated with delays in development,

ii. Congenital syndromes and conditions associated with delays in development,

iii. Sensory impairments associated with delays in development,

iv. Metabolic disorders associated with delays in development,

v. Prenatal and perinatal infections and significant medical problems associated with delays in development,

vi. Low birth weight infants weighing less than 1200 grams, or

vii. Postnatal acquired problems resulting in delays in development.

b. A child under five years of age who has the equivalence of twenty-five percent (25%) or greater delay in one or more of the five domains of development when compared with chronological age; or equivalence of 1.5 standard deviations or more below the mean in one or more of the five domains of development as determined by a qualified health professional utilizing appropriate diagnostic methods and procedures. The five domains are:

i. Adaptive development;

ii. Cognitive development;

iii. Communication development;

iv. Physical development, including vision and hearing; and,

v. Social or emotional development.

c. A child under three years of age who lives with one or both Parents who have been determined to have a Developmental Disability by a Case Management Agency.

22. Developmental Disabilities Professional means a person who has a bachelor's degree and a minimum of two years' experience in the field of Developmental Disabilities or a person with at least five years of experience in the field of Developmental Disabilities with competency in the following areas:

a. Understanding of civil, legal, and human rights;

b. Understanding of the theory and practice of positive and non-aversive behavioral intervention strategies; and

c. Understanding of the theory and practice of non-violent crisis and behavioral intervention strategies.

23. Developmental Disability means a disability that:

a. Is manifested before the person reaches 22 years of age;

b. Constitutes a substantial disability to the affected individual, as demonstrated by the criteria below at Subsections 8.7100.A.23.c.i and/or 8.7100.A.23.c.ii; and,

c. Is attributable to an Intellectual and Developmental Disability or related conditions which include Prader-Willi syndrome, cerebral palsy, epilepsy, autism, or other neurological conditions when such conditions result in impairment of general intellectual functioning or adaptive behavior similar to that of a person with an Intellectual and Developmental Disability. Unless otherwise specifically stated, the federal definition of "developmental disability" at 42 U.S.C. § 15002(8) shall not apply.

i. Impairment of general intellectual functioning means that the person has been determined to have a full-scale intellectual quotient equivalent which is two or more standard deviations below the mean (70 or less assuming a scale with a mean of 100 and a standard deviation of 15).

1) A secondary score comparable to the General Abilities Index for a Wechsler Intelligence Scale that is two or more standard deviations below the mean may be used only if a full-scale score cannot be appropriately derived.

2) Score shall be determined using a norm-referenced, standardized test of general intellectual functioning comparable to a comprehensively administered Wechsler Intelligence Scale or Stanford-Binet Intelligence Scales, as revised or current to the date of administration. The test shall be administered by a licensed psychologist or a school psychologist.

3) When determining the intellectual quotient equivalent score, a maximum confidence level of ninety percent (90%) shall be applied to the full-scale score to determine if the interval includes a score of 70 or less and shall be interpreted to the benefit of the Applicant being determined to have a Developmental Disability.

ii. Adaptive behavior similar to that of a person with intellectual disability means an overall adaptive behavior composite or equivalent score that is two or more standard deviations below the mean.

1) Measurements shall be determined using a norm-referenced, standardized Assessment of adaptive behaviors that is appropriate to the person's living environment and comparable to a comprehensively administered Vineland Scale of Adaptive Behavior, as revised or current to the date of administration. The Assessment shall be administered and determined by a professional qualified to administer the Assessment.

2) When determining the overall adaptive behavior score, a maximum confidence level of ninety percent (90%) shall be applied to the overall adaptive behavior score to determine if the interval includes a score of 70 or less and shall be interpreted to the benefit of the Applicant being determined to have a Developmental Disability.

d. A person shall not be determined to have a Developmental Disability if it can be demonstrated such conditions are attributable to only a physical or sensory impairment or a mental illness.

24. Early and Periodic Screening Diagnosis and Treatment (EPSDT) is as defined in Section 8.280.1.

25. Extraordinary Needs means Complex Behavior and/or Medical Support Needs that, without care provided in a residential childcare facility, would place a child at risk of unwarranted child welfare involvement or other system involvement.

26. Extreme Safety Risk to Self means a Member:

a. Displays self-destructiveness related to self-injury, suicide attempts, or other similar behaviors that seriously threaten the Member's safety; and,

b. Has a Rights Modification in accordance with Sections 8.7001 or 8.7001.B.4 or has a court order that imposes line of sight supervision unless the Member is in a controlled environment that limits the ability of the Member himself or herself.

27. Family as used in rules pertaining to support services and the Family Support Services Program means a group of interdependent persons residing in the same household that consists of a Family Member with a Developmental Disability or a child under the age of five years with a Developmental Delay, and one or more of the following:

a. A mother, father, brother(s), sister(s) or any combination; or,

b. Extended blood relatives such as grandparent(s), aunt(s) or uncle(s); or,

c. An adoptive Parent(s); or,

d. One or more persons to whom legal custody of a person with a Developmental Disability has been given by a court; or

e. A spouse and/or their children.

28. Financial Eligibility means eligibility based on the individual's financial circumstances, including income and resources.

29. Functional Eligibility means eligibility based on the criteria for Long-Term Services and Supports as determined by the Department's prescribed Assessment instrument, the Long-Term Services and Supports Level of Care Eligibility Determination Screen.

30. Functional Needs Assessment means a comprehensive, in-person evaluation using the Long-Term Services and Supports Level of Care Eligibility Determination Screen and medical verification provided using the Professional Medical Information Page to determine if the individual meets the institutional Level of Care (LOC).

31. Group Residential Services and Supports (GRSS) means residential habilitation provided in group living environments of four to eight Members receiving services who live in a single residential setting, which is licensed by the Colorado Department of Public Health and Environment as a residential care facility or residential community home for persons with Developmental Disabilities.

32. Grievance means the formal expression of a Complaint.

33. Guardian means an individual at least 21 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 as set forth in Section 15-14-102 (4), C.R.S, but not a Guardian Ad Litem.

34. Guardian Ad Litem means a person appointed by a court to act in the best interests of a child involved in a proceeding pursuant to Title 19, Article 3, C.R.S., or the "School Attendance Law of 1963," set forth in Title 22, Article 33, C.R.S.

35. Home and Community-Based Services (HCBS) waiver means services and supports authorized by a waiver granted pursuant to 42 U.S.C. 1396n(c) of 1935 (the Act) and provided in community settings to a Member who requires a level of institutional care that would otherwise be provided in a hospital, nursing facility, or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID).

36. Hospital Level of Care is as defined at 42 CFR § 440.10.

37. Inability for Independent Ambulation means

(1) the individual does not walk, and requires the use of a wheelchair or scooter in all settings, whether or not they can operate the wheelchair or scooter safely, on their own, or

(2) the individual does walk, but requires the use of a walker or cane in all settings, whether or not they can use the walker or cane safely, on their own, or

(3) the individual does walk but requires "touch" or "stand-by" assistance to ambulate safely in all settings.

38. Increased Risk Factors means situations or events that occur at a certain frequency or pattern historically that have led to Crisis.

39. Institution means a hospital, nursing facility, or Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) for which the Department makes Medicaid payment under the Medicaid State Plan.

40. Intellectual and Developmental Disability means a disability that manifests before the person reaches 22 years of age, that constitutes a substantial disability to the affected person, and that is attributable to an Intellectual and Developmental Disability or related conditions, including Prader-Willi syndrome, cerebral palsy, epilepsy, autism, or other neurological conditions when the condition or conditions result in impairment of general intellectual functioning or adaptive behavior similar to that of a person with an Intellectual and Developmental Disability. Unless otherwise specifically stated, the federal definition of "developmental disability" found in 42 U.S.C. sec. 15001 et seq., does not apply.

a. Impairment of general intellectual functioning means the person has been determined to have an intellectual quotient equivalent which is two or more standard deviations below the mean (70 or less assuming a scale with a mean of 100 and a standard deviation of 15), as measured by an instrument which is standardized, appropriate to the nature of the person's disability, and administered by a qualified professional. the standard error of measurement of the instrument should be considered when determining the intellectual quotient equivalent. When an individual's general intellectual functioning cannot be measured by a standardized instrument, then the Assessment of a qualified professional shall be used.

b. Adaptive behavior similar to that of a person with Intellectual and Developmental Disabilities means the person has overall adaptive behavior which is two or more standard deviations below the mean in two or more skill areas (communication, self-care, home living, social skills, community use, self-direction, health and safety, functional academics, leisure, and work), as measured by an instrument which is standardized, appropriate to the person's living environment, and administered and clinically determined by a qualified professional. These adaptive behavior limitations are a direct result of, or are significantly influenced by, the person's Substantial intellectual deficits and may not be attributable to only a physical or sensory impairment or mental illness.

41. Substantial intellectual deficit(s) means an intellectual quotient that is between 71 and 75 assuming a scale with a mean of 100 and a standard deviation of 15, as measured by an instrument which is standardized, appropriate to the nature of the person's disability, and administered by a qualified professional. the standard error of measurement of the instrument should be considered when determining the intellectual quotient equivalent.

42. Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) means a publicly or privately operated facility that provides health and habilitation services to a Member with an intellectual or Developmental Disability or related conditions.

43. Level of Care (LOC) means the specified minimum amount of assistance a Member must require to receive services in an institutional setting under the Medicaid State Plan.

44. Level of Care Assessment means a comprehensive evaluation with the Individual seeking services and others chosen by the Individual to participate, conducted by the Case Manager utilizing the Department's prescribed Assessment instrument, Long-Term Services and Supports Level of Care Eligibility Determination Screen, with supporting diagnostic information from the Individual's medical providers, to determine the Individual's level of functioning for admission or continued stay in Long-Term Services and Supports programs.

45. Level of Care Screen means an Assessment conducted in accordance with Section 8.7202.E.

46. Life-Limiting Illness means a medical condition or set of medical conditions that, in the opinion of the medical specialist involved, has a prognosis of death that is highly probable before the child reaches adulthood at age 19. A Life-Limiting Illness means a medical condition or set of condition that, in the opinion of the medical specialist involved, has a prognosis of death that is highly probable before the child reaches adulthood. Conditions that are incurable, irreversible, and that usually result in death are considered as one criterion for eligibility for the HCBS-CLLI waiver.

47. 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.

48. Medicaid Eligible means an individual meets the criteria for Medicaid benefits based on the individual's financial determination and disability determination when applicable.

49. Nursing Facility Level of Care is as defined at 42 CFR § 440.40.

50. Parent means the biological or adoptive Parent.

51. Professional Medical Information Page (PMIP) means the medical information form signed by a Licensed Medical Professional used to certify Level of Care.

52. Provider Agency means an Agency certified by the Department and which has a contract with the Department to provide one or more of the services listed at Section 8.7500.

52-A. Provisions for Compliance with Federal Cost Effectiveness means the person centered and needs based assessed approach in which HCBS waiver services are approved. They ensure HCBS waiver services are not duplicative, are based on assessed need of the member seeking services, and that services are the most economical and reliable means to meet an identified need of a member.

53. Public Safety Risk-Convicted means a factor in addition to specific Support Intensity Scale scores that is considered in the calculation of a Member's Support Level. This factor shall be identified when a Member has:

a. Been found guilty through the criminal justice system for a criminal action involving harm to another person or arson and who continues to pose a current risk of repeating a similar serious action; and,

b. A Rights Modification in accordance with Section 8.7001 or through parole or probation, or a court order that imposes line of sight supervision unless the Member is in a controlled environment that limits his or her ability to engage in the behaviors that pose a risk or to leave the controlled environment unsupervised.

54. Public Safety Risk-Not Convicted means a factor in addition to specific Support Intensity Scale scores that is considered in the calculation of a Member's Support Level. This factor shall be identified when a Member has:

a. Not been found guilty through the criminal justice system, but does pose a current and serious risk of committing actions involving harm to another person or arson; and,

55. Reassessment means a periodic reevaluation according to the requirements at Section 8.7200.B.27.

56. Referral means any notice or information (written, verbal, or otherwise) presented to a Case Management Agency that indicates that a person may be appropriate for services or supports provided through the disabilities system and for which the Case Management Agency determines that some type of follow-up activity for eligibility is warranted.

57. Respondent means a person participating in the Support Intensity Scale Assessment who has known the Member for at least three months and has knowledge of the Member and their abilities. The Respondent must have recently observed the Member in one or more places such as home, work, or in the community.

58. Request for Developmental Disability Determination means written document, either handwritten or a signed standardized form, which is submitted to a Case Management Agency requesting that a determination of Developmental Disability be completed.

a. Screening for Early Intervention Services means a preliminary review of how a child is developing and learning in comparison to other similarly situated children for the purpose of determining if early intervention services are medically necessary.

59. Seclusion means the placement of a Member alone in a closed room for the purpose of punishment. Seclusion for any purpose is prohibited.

60. Support Intensity Scale Interviewer means an individual formally trained in the administration and implementation of the Supports Intensity Scale by a Department-approved trainer using the Department-approved curriculum. Support Intensity Scale Interviewers must maintain a standard for conducting Support Intensity Scale Assessments as measured through periodic interviewer reliability reviews.

61. Support means any task performed for the Member where learning is secondary or incidental to the task itself or an adaptation is provided.

62. Supports Intensity Scale (SIS) means the standardized Assessment tool that gathers information from a semi-structured interview of Respondents who know the Member well. It is designed to identify and measure the practical support requirements of adults with Developmental Disabilities.

63. Support Level means a numeric value determined using an algorithm that places Members into groups with other Members who have similar overall support needs.

63-A. Target Group Criteria means the factors that define a specific population to be served through an HCBS waiver. Target Group Criteria can include physical or behavioral disabilities, chronic conditions, age, or diagnosis, and may include other criteria such as demonstrating an exceptional need.

64. TWWIIA Basic Coverage Group comprise working individuals who are at least 16 but less than 65 years of age who, except for their income and resource levels, are eligible to receive Supplemental Security Income (SSI).

65. Three Hundred Percent (300%) Eligible persons mean those:

a. Whose income does not exceed 300% of the SSI benefit level,

b. Who, except for the level of their income, would be eligible for an SSI payment, and

c. Who are not eligible for medical assistance (Medicaid) unless they are recipients in an HCBS program or are in a nursing facility or hospitalized for one calendar month.

66. Utilization Review Contractor (URC) means the Agency contracted with the Department to review the HCBS waiver applications for determination of eligibility based on the additional targeting criteria.

67. Utilization Review means a review conducting for the purpose of approving or denying admission or continued stay in the waiver based on Level of Care needs, clinical necessity, amount and scope, appropriateness, efficacy or efficiency of health care services, procedures, or settings.

68. Waiver Services means optional services defined in the current federally approved HCBS waiver documents and does not include Medicaid State Plan benefits.

8.7100.BEligible Persons

1. HCBS Waiver Services shall be offered to persons who meet all the eligibility requirements below provided the individual can be served within the capacity limits in the federal waiver. The HCBS waivers:

a. Shall not constitute an entitlement to services from the Department,

b. Shall be subject to annual appropriations by the Colorado General Assembly,

c. Shall ensure enrollments do not to exceed the federally approved capacity, and

d. May limit the individual waiver program's enrollment when utilization of the HCBS waiver program is projected to exceed legislative spending authority.

2. The section hereby incorporates terms and provisions of the federally approved HCBS waivers. To the extent that the terms of the federally approved waiver are inconsistent with the provisions of this section, the waiver(s) shall control.

8.7100.CFinancial Eligibility

1. Members shall meet the Medicaid Assistance eligibility criteria for Long Term Care as stated at Section 8.100.

2. The Applicant's income must be less than 300% of the current Supplemental Security Income Federal Benefit Rate and countable resources less than $2,000 for a single person or $3,000 for a couple.

3. Spousal impoverishment rules set forth at § 1924 of the Act are used to determine the eligibility of individuals with a community spouse for the special HCBS waiver group. In the case of a participant with a community spouse, the state shall use spousal post-eligibility rules as set forth at §1924 of the Act. Spousal impoverishment rules do not apply to people in the Medicaid Buy-In program.

4. The HCBS waiver programs provide services both for individuals eligible only for Medicaid and for individuals who are dually eligible for both Medicare and Medicaid.

a. Individuals may be eligible to participate in the adult HCBS waiver programs through the Medicaid Buy-in Program for Working Adults with Disabilities if all listed eligibility criteria listed at 8.100.6.P are met.

8.7100.DLevel of Care and Target Group

1. Individuals shall be referred to the Case Management Agency for an initial HCBS eligibility determination. The Long-Term Services and Supports Level of Care (LOC) eligibility determination screen is used to determine an individual's need for institutional Level of Care.

2. The state-prescribed Assessment instrument shall measure six defined Activities of Daily Living (ADLs) and the need for supervision for behavioral, executive or cognitive dysfunction. ADLs include bathing, dressing, toileting, mobility, transferring, and eating.

3. Level of Care Assessments and Reassessments shall be performed by Case Management Agencies and utilize the same instrument in determining the Level of Care for the waiver as for State Plan institutional care.

4. The individual also must be at risk of placement in an Institution within one month, but for the availability of Waiver Services. See individual waiver program for specific Level of Care requirements.

5. For initial Level of Care eligibility determinations, the Professional Medical Information Page (PMIP) shall be completed by a treating medical professional who verifies the individual's qualifying diagnoses or conditions.

6. The individual must require Long-Term Services and Supports to remain in their own home, in the Family residence, or in the community.

7. To utilize HCBS Waiver Benefits, the individual must choose to receive services in their home or community.

8. The cost of HCBS Waiver Services shall not be greater than the cost of placement in an Institution and the individual's safety and health can be assured in the community within the federally approved capacity and the aggregate cost containments of the enrolled waiver program.

9. The Case Management Agency shall certify HCBS waiver eligibility only for those individuals:

a. Determined by the Case Management Agency to meet the target group designation for one or more waiver programs detailed in the Target Group Criteria section of each HCBS waiver program at Section 8.7101.

b. Determined by a Level of Care Assessment to require the Level of Care available in an Institution according to Section 8.401; or

c. A length of stay shall be assigned by the Case Management Agency for approved admissions according to guidelines at Section 8.402.

8.7100.EReceiving HCBS Waiver Services

1. Only Members who receive HCBS Waiver Services as defined at Section 8.7500, or who have agreed to accept HCBS services when eligibility criteria have been met are eligible for an HCBS waiver program.

a. Case Management is not a waiver service and shall not be used to satisfy this requirement.

b. Desire or need for home health services or other Medicaid State Plan services that are not identified as HCBS Waiver Services shall not satisfy this eligibility requirement.

2. HCBS waiver program Members who have received no HCBS Waiver Services for one calendar month shall be discontinued from the program.

3. Members may not be simultaneously enrolled in more than one HCBS waiver.

8.7100.FInstitutional Status

1. Members who are residents of Institutions are not eligible for HCBS Waiver Services while residing in such Institutions.

2. A Member enrolled in an HCBS waiver and who is admitted to a hospital may not receive HCBS Waiver Services while residing in the hospital. If the Member resides in the hospital for a continuous period of one month or more, the Case Manager shall terminate the Member from the HCBS waiver program.

3. A Member enrolled in an HCBS waiver and who is admitted to a nursing facility or ICF-IID may not receive HCBS Waiver Services while in the nursing facility or Intermediate Care Facilities for Individuals with Intellectual Disabilities, except as provided below:

a. If Medicaid pays for all or part of the nursing facility care or Intermediate Care Facilities for Individuals with Intellectual Disabilities, or if the Case Manager verifies that a Long-Term Services and Supports Level of Care Eligibility Determination Screen has been completed for the nursing facility or Intermediate Care Facilities for Individuals with Intellectual Disabilities placement, the Case Manager must terminate the Member from the HCBS waiver program.

b. A Member enrolled in an HCBS waiver who enters a nursing facility for HCBS respite care shall not be required to obtain a Long-Term Services and Supports Level of Care Eligibility Determination Screen and shall not be terminated from the HCBS waiver program.

c. Nothing in this section is intended to create a right to receive respite care services pursuant to the Waiver Benefit if respite care services are not included in the waiver.

8.7100.GProvisions for Compliance with Federal Cost Effectiveness

1. The Department of Health Care Policy and Financing shall conduct periodic aggregate cost effectiveness analyses per federal requirements and in partnership with the Centers for Medicare and Medicaid.

8.7100.HMaintenance of HCBS Waiver Eligibility

1. The Member shall maintain eligibility by meeting General Eligibility and waiver program-specific requirements set forth herein subject to the following:

a. Reevaluation of the Member to verify Medicaid, financial, and program eligibility is required within twelve months following any previous Assessment. The Continued Stay Review will follow the same procedures set forth at Section 8.401.11-.17(H).

b. The Member must receive at least one HCBS waiver service each calendar month.

c. The Member must not be simultaneously enrolled in any other HCBS waiver program.

d. The Member must not be residing in an Institution, correctional facility, or other Institution.

8.7100.IWaiting List

1. Individuals who are determined eligible for a HCBS Waiver Services, who cannot be served within the capacity limits of the federally-approved waiver, shall be eligible for placement on the waiting list for a HCBS waiver for which they applied. A separate waiting list shall be maintained for each waiver.

a. The Department shall maintain the waiting list.

b. The date of initial determination of eligibility for an HCBS waiver shall determine the individual's position on the waiting list.

c. As openings become available within the capacity limits of the federal waiver, individuals shall be considered for services based on the criteria in order of priority as follows:

i. Individuals being Deinstitutionalized from nursing facilities or Intermediate Care Facilities for Individuals with Intellectual Disabilities.

ii. Individuals being discharged from a hospital who, without Waiver Services, would be discharged to an Institution at a greater cost to Medicaid.

iii. Individuals, currently receiving long-term home health benefits, whose services could be delivered at a lower cost through a Waiver Benefit.

iv. Members with high Long-Term Services and Supports Level of Care Eligibility Determination Screen scores who are at imminent risk of Institutional placement.

d. Individuals denied program enrollment shall be informed of their appeal rights in accordance with Section 8.057.

8.7100.JTermination

1. The Department shall discontinue a Member's enrollment in an HCBS waiver when one of the following occurs:

a. The Member no longer meets the HCBS Waiver Benefit criteria,

b. The Member dies,

c. The Member enrolls in another HCBS waiver program or is admitted for a long-term stay beyond one month in an Institution, or

i. The Member does not receive an HCBS waiver service during a full one-month period, or

ii. The Member voluntarily withdraws from the HCBS waiver program.

10 CCR 2505-10-8.7100

47 CR 03, February 10, 2024, effective 3/16/2024

47 CR 23, December 10, 2024, effective 12/30/2024