10 Colo. Code Regs. § 2505-10-8.7101

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

Section 10 CCR 2505-10-8.7101 - HCBS Waiver Program-Specific Member Eligibility

8.7101.AChildren's HCBS Waiver (CHCBS)

1. Target Group Criteria:

2. To be eligible for the HCBS-CHCBS waiver, a child shall meet the following Target Group Criteria:

a. Is under 18 years of age.

b. Lives at home with Parent(s) or Guardian.

c. Meets Hospital Level of Care the state additionally limits the waiver to the subcategory of acute Hospital Level of Care or Nursing Facility Level of Care the State additionally limits the waiver to the subcategory of skilled nursing facilities Level of Care.

d. Meets federal SSI disability definition.

e. The child's Parent(s) or Guardian chooses to receive services in the home or community instead of an Institution.

f. The child is not otherwise eligible for Medicaid benefits or enrolled in other Medicaid waiver programs due to parental income and/or resources.

3. Medicaid Eligibility Groups Served in the Waiver

a. CHCBS Waiver Services are available to eligible individuals who meet the criteria set forth at 42 CFR § 435.217.

4. Other

a. To be eligible for the CHCBS waiver, the income and resources of the child shall not exceed 300% of the current maximum Social Security Insurance (SSI) standard maintenance allowance.

b. Individuals who meet eligibility criteria for the CHCBS waiver and cannot be served within the federally approved waiver capacity limits shall be eligible for placement on a waiting list maintained by the Utilization Review Contractor (URC).

c. A child on the waiting list shall be prioritized for enrollment in the waiver if they meet any of the following criteria:

d. Have been in a hospital for one month or longer and require Waiver Services in order to be discharged from the hospital.

e. Are on the waiting list for an organ transplant.

f. Are dependent upon mechanical ventilation or prolonged intravenous administration of nutritional substances.

g. Have received a terminally ill prognosis from their physician.

8.7101.BChildren's Extensive Support Waiver (HCBS-CES)

1. Target Group Criteria

2. To be eligible for the HCBS-CES waiver, an individual shall meet the Target Group Criteria as follows:

a. Is unmarried and under 18 years of age.

b. Has a Developmental Disability (which includes a Developmental Delay if under five years of age) and requires long term services and supports to remain in the Family home.

c. Meets Intermediate Care Facilities for Individuals with Intellectual Disabilities Level of Care as determined by the Level of Care Screen.

d. Resides in an eligible HCBS-CES waiver setting, defined as:

i. Residing with biological or adoptive Parent(s), or Legal Guardian, or

ii. Residing in an out-of-home placement and can return home with the provision of HCBS-CES Waiver Services with the following requirements:

1) The Case Manager shall work with the residential caregiver to develop a transition plan that includes timelines and identified services or supports requested during the time the Member is not residing in the Family home. The Case Manager shall submit the transition plan to the Department for approval prior to the start of services.

iii. Meets the definition of disability set forth at 42 U.S.C. § 423(d).

iv. Meets the HCBS-CES waiver Member eligibility criteria:

1) The individual demonstrates a behavior or has a medical condition that requires direct human intervention, more intense than a verbal reminder, redirection, or brief observation of status, at least once every two hours during the day and on a weekly average of once every three hours during the night. The behavior or medical condition must be considered beyond what is typically age appropriate and due to one or more of the following conditions:

a) A significant pattern of self-endangering behavior or medical condition which, without intervention will result in a life-threatening condition or situation,

b) A significant pattern of serious aggressive behavior toward self, others, or property, or

c) Constant vocalizations such as screaming, crying, laughing, or verbal threats which cause emotional distress to caregivers. The term constant is defined as on the average of 15 minutes each waking hour.

2) For purposes of this subsection 6, Significant Pattern is defined as a behavior or medical condition that is harmful to self or others as evidenced by actual events occurring within the past six (6) months.

3) To remain eligible for Waiver Services, the annual Reassessment must demonstrate that in the absence of the existing interventions or preventions provided as Waiver Services, the intensity and frequency of the behavior or medical condition would return to a level that would meet the criteria listed above.

3. Medicaid Eligibility Groups Served in the Waiver

a. HCBS-CES Waiver Services are available to eligible Individuals in the following State Plan eligibility groups:

i. SSI recipients

ii. Optional state plan recipients

4. Other

a. Individuals who are determined eligible for HCBS-CES Waiver Benefits who cannot be served within the capacity limits of the federally approved waiver, shall be eligible for placement on a waiting list maintained by the Department.

8.7101.CChildren's Habilitation Residential Program Waiver (HCBS-CHRP)

1. Target Group Criteria

2. To be eligible for the HCBS-CHRP waiver, an individual shall meet the Target Group Criteria as follows:

a. Is under 21 years of age.

b. Has a Developmental Disability (which includes Developmental Delay if under five years of age).

c. Has Extraordinary Needs that put the individual at risk or in need of out-of-home placement.

d. Meets Intermediate Care Facilities for Individuals with Intellectual Disabilities Level of Care as determined by the Level of Care Screen.

3. Medicaid Eligibility Groups Served in the Waiver

4. HCBS-CHRP Waiver Services are available to eligible Members in the following State Plan eligibility groups:

a. Children for whom foster care maintenance payments are being made by the County Departments of Human/Social Services and who otherwise meet eligibility criteria.

b. Individuals who meet the criteria set forth at 42 CFR § 435.217.

5. Other

a. An Assessment of the level of support needed shall be completed upon determination of eligibility and shall determine the level of reimbursement for Habilitation and per diem Respite services.

b. Individuals determined eligible for benefits under the HCBS-CHRP waiver, who cannot be served within the capacity limits of the federally approved waiver, shall be eligible for placement on a waiting list maintained by the Department.

8.7101.DChildren with Life-Limiting Illness Waiver (HCBS-CLLI)

1. Target Group Criteria:

2. To be eligible for the HCBS-CLLI waiver, an individual shall meet the Target Group Criteria as follows:

a. Is under 19 years of age,

b. Has been diagnosed with a Life-Limiting Illness (i.e., a life-limiting medical condition or set of life-limiting medical conditions) as certified by a physician on the Department-prescribed form, the Professional Medical Information Page,

c. Meets Hospital Level of Care as determined by the Case Manager using the Long-Term Services and Supports Level of Care Screen, and

d. Lives in their Family home.

3. Medicaid Eligibility Groups Served in the Waiver:

4. HCBS-CLLI Waiver Services are available to eligible individuals in the following State Plan eligibility groups:

a. SSI recipients

b. Optional state plan recipients

5. Other

a. Individuals who are determined eligible for benefits under the HCBS-CLLI waiver, and who cannot be served within the capacity limits of the federally approved waiver, shall be eligible for placement on a waiting list maintained by the Department.

8.7101.EPersons with Brain Injury Waiver (HCBS-BI)

1. Target Group Criteria

2. To be eligible for the HCBS-BI waiver, an individual shall meet the Target Group Criteria as follows:

a. Is determined to have a Brain Injury that occurred prior to the individual's 65^th birthday.

i. Brain Injury is defined as an injury to the brain of traumatic or acquired origin which results in residual physical, cognitive, emotional, and/or behavioral difficulties of a non-progressive nature and is limited to the to the broad diagnoses found within the most current version of the ICD.

b. Is 16 years of age or older.

c. Meets Nursing Facility Level of Care;

d. Meets Hospital Level of Care and as evidenced by:

i. The individual shall have been:

1) Referred to the Case Management Agency while receiving inpatient care in an acute care or rehabilitation hospital for the treatment of the individual's Brain Injury; or

2) A comprehensive functional Assessment using the Long-term Services and Supports Level of Care Screen results in at least the minimum scores required by Section 8.7202.E, demonstrating a functional need for nursing facility Level of Care.

ii. The individual shall require goal-oriented therapy with medical management by a physician.

iii. The individual shall not be therapeutically managed in a community-based setting without significant supervision and structure, specialized therapy, and support services.

3. Medicaid Eligibility Groups Served in the Waiver

4. HCBS-BI Waiver Services are available to eligible Members in the following State Plan eligibility groups:

a. SSI recipients

b. Optional state plan recipients

c. Working individuals with disabilities who buy into Medicaid (BBA Working Disabled Group as described in 42 U.S.C § 1902 1396a(a)(10)(A)(ii) (XIII))

d. Working individuals with disabilities who buy into Medicaid TWWIIA Basic Coverage Group as provided in 42 U.S.C. § 1396a(a)(10)(A)(ii) (XV of the Act)

5. Other

a. Persons determined eligible for HCBS-BI services that cannot be served within the capacity limits of the HCBS-BI waiver shall be eligible for placement on a waiting list maintained by the Department.

8.7101.FCommunity Mental Health Supports Waiver (HCBS-CMHS)

1. Target Group Criteria

2. To be eligible for the HCBS-CMHS waiver, an individual shall meet the Target Group Criteria as follows:

a. Is experiencing a severe and persistent mental health need that requires assistance with one or more ADLs. For purposes of this subsection, a person experiencing a severe and persistent mental health need is defined as one who:

i. Is 18 years of age or older with a severe and persistent mental health need,

ii. Currently has or at any time during the one-year period prior to Assessment had a diagnosed mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within the Diagnostic and Statistical Manual of Mental Disorders (DSM -5):

1) Has a disorder that is episodic, recurrent, or has persistent features, but may vary in terms of severity and disabling effects; and

2) Has resulted in functional impairment which substantially interferes with or limits one or more major life activities, and

iii. A severe and persistent mental health need does not include:

1) Intellectual or developmental disorders; or

2) Substance use disorder without a co-occurring diagnosis of a severe and persistent mental health need.

b. Meets Nursing Facility Level of Care.

c. A length of stay shall be assigned by the Utilization Review Contractor (URC) for approved admissions, according to guidelines at Section 8.402.30.

3. Medicaid Eligibility Groups Served in the Waiver

4. HCBS-CMHS Waiver Services are available to eligible Members in the following State Plan eligibility groups:

a. SSI recipients

b. Optional state plan recipients

c. Working individuals with disabilities who buy into Medicaid BBA Working Disabled Group as described in described in 42 U.S.C § 1396a(a)(10)(A)(ii) (XIII)

d. Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as provided in §1396a(a)(10)(A)(ii)(XV) of the Act

8.7101.GElderly, Blind, And Disabled Waiver (HCBS-EBD)

1. Target Group Criteria

2. To be eligible for the HCBS-EBD waiver, an individual shall meet the Target Group Criteria as follows:

a. Is determined by the Case Management Agency to meet the target group definition for functionally impaired elderly, or the target group definition for physically disabled or blind adult.

b. Meets the minimum and/or if applicable maximum age for individuals served in each subgroup

c. Aged: Be 65 years of age or older

i. Physically Disabled or Blind: Be 18-64 years of age (Those participants who are physically disabled who reach the age of 65 shall automatically get classified as Aged with no break in services), and/or

ii. HIV/AIDS: Be 18 years of age or older.

d. Meets Nursing Facility Level of Care.

3. Medicaid Eligibility Groups Served in the Waiver

4. HCBS-EBD Waiver Services are available to eligible Members in the following State Plan eligibility groups:

a. SSI recipients

b. Optional state plan recipients

c. Working individuals with disabilities who buy into Medicaid (BBA Working Disabled Group as described in §1396a (a)(10)(A)(ii)(XIII))

d. Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as provided in §1396a (a)(10)(A)(ii)(XV) of the Act

5. Other

a. HCBS-EBD Members that enter a nursing facility or hospital may not receive HCBS-EBD Waiver Services while residing in the nursing facility or hospital unless prior authorization has been received from the Department.

i. HCBS-EBD Members admitted to a nursing facility or hospital for one calendar month or longer shall be discontinued from the HCBS-EBD program.

ii. HCBS-EBD Members entering a nursing facility for Respite Care as an HCBS-EBD service shall not be discontinued from the HCBS-EBD program.

b. Individuals determined eligible for HCBS-EBD services that cannot be served within the capacity limits of the HCBS-EBD waiver shall be eligible for placement on a waiting list.

8.7101.HComplementary and Integrative Health Waiver (HCBS-CIH)

1. Target Group Criteria

2. To be eligible for the HCBS-CIH waiver, an individual shall meet the Target Group Criteria as follows:

a. Is 18 years of age or older.

b. Has a qualifying condition of a spinal cord injury (traumatic or nontraumatic), multiple sclerosis, a Brain Injury, spina bifida, muscular dystrophy, or cerebral palsy with the Inability for Independent Ambulation directly resulting from one of these conditions as defined by broad diagnoses related to each condition within the most current version of the ICD at the time of Assessment.

c. Be unable to ambulate independently as a result of the qualifying condition as identified by the Case Manager through the Level of Care Screen process. A person is considered unable to ambulate independently if:

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

ii. The individual does walk, but requires the use of a walker or cane in all settings, whether they can use the walker or cane safely, on their own; or

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

d. Meets Hospital Level of Care or Nursing Facility Level of Care.

3. Medicaid Eligibility Groups Served in the Waiver

a. HCBS-CIH Waiver Services are available to eligible individuals in the following State Plan eligibility groups:

i. SSI recipients

ii. Optional state plan recipients

iii. Working individuals with disabilities who buy into Medicaid (BBA Working Disabled Group as described in 42 U.S.C § 1396a(a)(10)(A)(ii) (XIII)).

iv. Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as provided in §1396a(a)(10)(A)(ii)(XV) of the Act

4. Other

a. Persons determined eligible for HCBS-CIH services that cannot be served within the capacity limits of the HCBS-CIH waiver shall be eligible for placement on a waiting list.

8.7101.ISupported Living Services Waiver (HCBS-SLS)

1. Target Group Criteria

2. To be eligible for the HCBS-SLS waiver, an individual shall meet the Target Group Criteria as follows:

a. Has an intellectual or Developmental Disability

b. Is 18 years of age or older.

c. Meets the Intermediate Care Facilities for Individuals with Intellectual Disabilities Level of Care.

d. Does not require 24-hour supervision on a continuous basis which is reimbursed as an HCBS-SLS service.

e. Resides in an eligible HCBS-SLS setting. An SLS setting is the individual's residence, which is defined as the following:

i. A living arrangement, which the individual owns, rents, or leases in their own name,

ii. The home where the individual lives with the Member's Family or legal Guardian, or

iii. A living arrangement of no more than three persons receiving HCBS Waiver Services residing in one household, unless they are all Members of the same family.

3. Medicaid Eligibility Groups Served in the Waiver

4. HCBS-SLS Waiver Services are available to eligible Members in the following State Plan eligibility groups:

a. SSI recipients

b. Optional state plan recipients

c. Working individuals with disabilities who buy into Medicaid (BBA Working Disabled Group as described in 42 U.S.C § 1396a(a)(10)(A)(ii) (XIII)).

d. Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as provided in §1396a(a)(10)(A)(ii)(XV) of the Act

5. Other

a. Enrollment in the HCBS-SLS waiver may be limited when utilization of the HCBS-SLS waiver program is projected to exceed legislative pending authority.

b. When the HCBS-SLS waiver reaches capacity for enrollment, an individual determined eligible for a waiver shall be placed on a waiting list.

c. As openings become available in the HCBS-SLS waiver program in a designated service area, individuals shall be considered for services in order of placement on the local Case Management Agency's waiting list regarding an appropriate match to services and supports. Exceptions to this requirement shall be limited to situations in which:

i. An emergency greatly endangers the health, safety, and welfare of the individual or others and the emergency cannot be resolved in another way. For the purposes of this subsection, emergencies are defined as follows:

1) Homelessness: the individual does not have a place to live or is in imminent danger of losing their place of abode.

2) Abusive or Neglectful Situation: the individual is experiencing ongoing physical, sexual, or emotional abuse or neglect in their present living situation and their health, safety or well-being are in serious jeopardy.

3) Danger to Others: the individual's behavior or psychiatric is such that others in the home are at risk of being hurt by them. Sufficient supervision cannot be provided by the current caretaker to ensure the safety of persons in the community.

4) Danger to Self: an individual's medical, psychiatric, or behavioral challenges are such that they are seriously injuring/harming themselves or are in imminent danger of doing so.

d. The Legislature has appropriated funds specific to individuals or to a specific class of persons.

e. If an eligible individual is placed on a waiting list for SLS Waiver Services, a written notice, including information regarding the Member appeals process, shall be sent to the individual and/or his/her legal Guardian in accordance with the provisions of Section 8.057, et seq.

8.7101.J Developmental Disabilities Waiver (HCBS-DD)

1. Target Group Criteria

2. To be eligible for the HCBS-DD waiver, an individual shall meet the Target Group Criteria as follows:

a. Has an intellectual or Developmental Disability.

b. Requires access to 24-hour services and supports to meet daily living needs that allow them to live safely and participate in the community.

c. Is 18 years of age or older.

d. Meets Intermediate Care Facilities for Individuals with Intellectual Disabilities Level of Care.

3. The State may limit the number of Members enrolled in the HCBS-DD waiver at any point in time during a waiver year. When the HCBS-DD waiver reaches capacity for enrollment, an individual determined eligible for the waiver shall be eligible for placement on a waiting list.

a. The state reserves capacity for the following purposes:

i. Emergency in which positions are reserved for individuals whose names are on the waiting list, who are experiencing a Crisis, and require immediate assistance to ensure their health and safety,

ii. 18-21 Transition in which positions made available for children who are adopted through the Colorado Child Welfare system, reach an age at which they are no longer eligible for foster care, the HCBS-Children's Extensive Supports waiver, or the HCBS-Children's Habilitation Residential Program waiver in order to continue access to services that will allow them to continue living safely in the community without interruption, and

iii. Deinstitutionalization for Nursing Facility, Intermediate Care Facilities for Individuals with Intellectual Disabilities, and State Mental Health Institutes in which positions are made available for individuals who have requested to transition from one of these settings to a community setting, and

iv. Waitlists. As vacancies occur in waiver enrollments, the state shall enroll the next individual on the waiting list based on the statewide order of the selection date.

4. Medicaid Eligibility Groups Served in the Waiver

5. HCBS-DD Waiver Services are available to eligible Members in the following State Plan eligibility groups:

a. SSI recipients

b. Optional state plan recipients

c. Working individuals with disabilities who buy into Medicaid (BBA Working Disabled Group as Medicaid as described in 42 U.S.C § 1396a(a)(10)(A)(ii) (XIII))

d. Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as described in 42 U.S.C. § 1396a(a)(10)(A)(ii)(XV) of the Act

6. Other

a. The Member shall maintain eligibility by meeting the General Eligibility and waiver program-specific requirements set forth herein and maintaining residence in a GRSS or IRSS setting.

b. Enrollment in the HCBS-DD waiver may be limited when utilization of the HCBS-DD waiver program is projected to exceed legislative pending authority.

c. When the HCBS-DD waiver reaches capacity for enrollment, an individual determined eligible for a waiver shall be placed on a waiting list.

d. As openings become available in the HCBS-DD waiver program, individuals shall be considered for services in order of placement on the statewide waiting list. Exceptions to this requirement shall be limited to situations in which:

1) Homelessness: the individual does not have a place to live or is in imminent danger of losing their place of abode.

4) Danger to Self: an individual's medical, psychiatric, or behavioral challenges are such that they are seriously injuring/harming themselves or are in imminent danger of doing so.

5) Loss or Incapacitation of Primary Caregiver: a person's primary caregiver is no longer in the person's primary residence to provide care; or the primary caregiver is experiencing a chronic, long-term, or life-threatening physical or psychiatric condition that significantly limits the ability to provide care; or the primary caregiver is age 65 years or older and continuing to provide care poses an imminent risk to the health and welfare of the person or primary caregiver; or, regardless of age and based on the recommendation of a professional, the primary caregiver cannot provide sufficient supervision to ensure the person's health and welfare.

e. The Legislature has appropriated funds specific to individuals or to a specific class of persons.

f. If an eligible individual is placed on a waiting list for DD Waiver Services, a written notice, including information regarding the Member appeals process, shall be sent to the individual and/or his/her legal Guardian in accordance with the provisions of Section 8.057, et seq.

10 CCR 2505-10-8.7101

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

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