10 Colo. Code Regs. § 2505-10-8.7200
Current through Register Vol. 47, No. 24, December 25, 2024
Section 10 CCR 2505-10-8.7200 - Case Management Agency Requirements8.7200.AColorado Case Management System1. The Colorado Case Management System consists of Case Management agencies representing defined service areas throughout the state, for the purpose of providing assistance to persons in need of long-term services & support, including but not limited to Home and Community-Based Services.8.7200.B. Definitions Unless otherwise specified, the following definitions apply throughout Sections 8.7000-7500.
1. Assessment means a comprehensive evaluation with the individual seeking services and appropriate supports (such as Family Members, advocates, friends and/or caregivers), chosen by the individual, conducted by the Case Manager, with supporting diagnostic information from the individual's medical provider to determine the individual's level of functioning, service needs, available resources, and potential funding resources.1-A. 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 one of the holidays listed in Section 24-11-101(1), C.R.S.2. Case Management Agency is defined in 8.7100.A.83. Case Management Agency Defined Service Area means one or more counties that have been designated as a geographic region in which one Agency serves as the Case Management Agency for persons in need of Home and Community-Based Waiver Services or Long Term Services and Supports.4. Case Management Activities means the Assessment of an individual seeking or receiving Long-Term Services and Supports' needs, the development and implementation of a Person-Centered Support Plan for such individual, Referral and related activities, the coordination and monitoring of long-term service delivery, the evaluation of service effectiveness, and the periodic Reassessment of such individual's needs and collaboration with other entities impacting the Members' HCBS, health and welfare. a. Case Management Activities means all activities performed by a Case Management Agency reimbursed through contracts and Targeted Case Management. i. Administrative Case Management includes activities that are reimbursed through contracts with the Department of Health Care Policy and Financing.ii. Targeted Case Management refers to coordination and planning services provided with, or on behalf of, an individual Member. Targeted Case Management is a state plan benefit and is reimbursed through direct billing not contract payments.5. Case Manager means an employee of a Case Management Agency, as defined at 8.7100.A.8, who performs the required Case Management Activities.6. Colorado General Assembly means the legislature of the State of Colorado, comprising both the state senate and the state house of representatives.7. Community Centered Board (CCB) means a private for-profit or not-for-profit organization that is an administrator of locally generated funding pursuant to CRS 25.510-206(6) and acts as a resource for persons with an Intellectual and Developmental Disability or a child with a Developmental Delay.8. Complaint means any statement received by an individual or Member as it relates to unsatisfactory services provided through the Case Management Agency to include, but not limited to: general business functions, administration, State General Fund program functions, and Case Management functions. Complaints regarding activities outside the scope of work for the Case Management Agency are excluded from this definition.9. Conflict Free Case Management means Members enrolled in any Long-Term Services and Supports programs and/or Home and Community-Based Services waivers must receive direct Home and Community-Based Services and Case Management from separate entities.10. Conflict-Free Case Management Waiver means the Case Management Agency may provide direct services to Members for whom it provides Case Management services.11. Corrective Action Plan means a written plan by the Case Management Agency, which includes a detailed description of actions to be taken to correct non-compliance with waiver requirements, regulations, and 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.12. Critical Incident means an actual or alleged event that creates the risk of serious harm to the health or welfare of a Member; including events that may endanger or negatively impact the mental and/or physical well-being of an individual. Critical Incidents include, but are not limited to, injury/illness; abuse/neglect/exploitation; damage/theft of property; medication mismanagement; lost or missing person; criminal activity; unsafe housing/displacement; or death.13. Defined Service Area means the geographical area the Department determines shall be served by a Case Management Agency.14. Department means the Colorado Department of Health Care Policy and Financing, the Single State Medicaid Agency.15. Home and Community-Based Services (HCBS) Waivers is as defined in Waiver Eligibility Requirements Section 8.7100 et seq..16. Intellectual and Developmental Disability has the same meaning set forth in Section 25.5-6-403 (3.3)(a) C.R.S and 8.7100.A.40.17. Information Management System (IMS) means an automated data management system approved by the Department to enter Case Management information for each individual seeking or receiving long-term services as well as to compile and generate standardized or custom summary reports.18. Intake, Screening and Referral means the initial contact with individuals by the Case Management Agency and shall include, but not be limited to, a preliminary screening in the following areas: an individual's need for Long-Term Services and Supports; an individual's need for Referral to other programs or services; an individual's eligibility for financial and program assistance; and the need for a comprehensive Functional Needs Assessment of the individual seeking services.19. 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. Long term Services and Supports includes but is not limited to long term care such as nursing facility care as part of the standard Medicaid benefit package and Home and Community-Based Services provided under waivers granted by the Federal government.20. Long Term Services and Supports Level of Care Eligibility Determination Screen (Level of Care Screen) means a comprehensive evaluation with the individual seeking services and appropriate support persons (such as Family Members, friends, and or caregivers) to determine an Applicant or Member's eligibility for Long-Term Services and Supports based on their need for institutional Level of Care as determined using the Department's prescribed Assessment instrument as outlined in Section 8.7202.E.21. Long Term Services and Supports (LTSS) Program means any of the following: publicly funded programs, Medicaid Nursing Facility Care, Program for All-Inclusive Care for the Elderly (PACE) (where applicable), Hospital Back-up (HBU) and Adult Long-Term Home Health (LTHH). a. Children's Home and Community-Based Services (HCBS-CHCBS)b. Developmental Disabilities (HCBS-DD)c. Home and Community-Based Services for the Elderly, Blind and Disabled (HCBS-EBD)d. Home and Community-Based Services Complementary and Integrative Health (HCBS-CIH)e. Home and Community-Based Services for Persons with a Brain Injury (HCBS-BI)f. Home and Community-Based Services Community Mental Health Supports (HCBS-CMHS)g. Home and Community-Based Services for Children with Life Limiting Illness (HCBS-CLLI), andh. Home and Community-Based Services Supported Living Services (HCBS-SLS)i. Children's Extensive Support Waiver (HCBS-CES)j. Children's Habilitative Residential Program (HCBS-CHRP)22. Member means as defined in 8.7001.A.8-B.23. Member Identified Team means the people, agencies or representatives a Member selects to participate to support in their long-term care programs, processes and procedures including but not limited to their service planning or other waiver program processes and procedures. Members may choose specific people or agencies and may select which portions of their program they want the team to be involved with. Members may revoke or change this team at any time. "Member Identified Team" applies to all waivers and replaces Interdisciplinary Team in former rules applicable to people with Intellectual and Developmental Disabilities.24. Pre-Admission Screening and Resident Review (PASRR) is as defined in 8.401.18.24-A. 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. The review shall include a review of required case management services performed by the agency to ensure quality and compliance with all requirements.25. Person-Centered Case Management means Case Management services that offer people dignity, compassion and respect while facilitating Assessments and planning that support people to recognize and develop their own strengths and abilities to enable them to live an independent and fulfilling life.26. Person-Centered Support Planning means the process of working with the Member and people chosen by the individual to identify goals, needed services, individual choices and preferences, and appropriate service providers based on the individual seeking or receiving services' Assessment and knowledge of the individual and of community resources. Support Planning informs the individual seeking or receiving services of his or her rights and responsibilities.26-A. 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.26-B. Post Eligibility Treatment of Income (PETI) means the calculation used to determine the Member's obligation (payment) for the payment of residential services.27. Reassessment means a periodic reevaluation with the Member, their chosen supports, and Case Manager, to re-determine the individual's level of functioning, service needs, available resources and potential funding resources.27-A. Regional Center means as defined at § 24-10.5-102, C.R.S.27-B. Service Plan Authorization Limit (SPAL) means an annual upper payment limit of total funds available to purchase services to meet the Member'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 Members in each level, and projected utilization.28. State General Fund (SGF) Programs means programs funded solely through the Colorado State General Fund. Those include but are not limited to: State Supported Living Services (State-SLS) at Section 8.7202.V.3, Specialized Nursing Care Services as set forth at 42 C.F.R. Chapter IV, Subchapter G, Part 483 (OBRA-SS), and Family Support Services Program (FSSP) at Section 8.7558.28-A. Supports Intensity Scale (SIS) means as defined at 8.7100.A.62.28-B. Support Level means as defined at 8.7100.A.63.29. Target Group Criteria means as defined at 8.7100.A.63-A.29-A. Targeted Case Management (TCM) means case management services provided to Members enrolled in the HCBS waivers in accordance with Section 8.760 et seq,30. 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 coordination services for those transitioning from facility-based care to community-based care pursuant to a Provider Participation Agreement with the state department.31. Waiver Benefit means covered benefits offered in addition to or as an alternative to state plan benefits as authorized by 42 U.S.C. 1396n © and include the Waiver Benefits described in Section 8.7101 for the following programs: Children's Home and Community-Based Services Waiver (CHCBS); Children's Extensive Support Waiver (HCBS-CES); Children's Habilitation Residential Program Waiver (HCBS-CHRP); Children With Life Limiting Illness Waiver (HCBS-CLLI); Persons With Brain Injury Waiver (HCBS-BI); Community Mental Health Supports Waiver (HCBS-CMHS); Elderly, Blind and Disabled Waiver (HCBS-EBD); Complementary and Integrative Health Waiver (HCBS-CIH; Supported Living Services Waiver (HCBS -SLS); and Developmental Disabilities Waiver (HCBS-DD).8.7200.CLegal Basis1. Pursuant to Section 25.5-6-1701, C.R.S., the State Department is authorized to provide for a statewide Case Management system.8.7200.DCase Management Agency Defined Service Areas1. Case Management Agency Defined Service Areas shall meet the following requirements:2. Counties composing a multi-county service area shall be contiguous.3. A single county may be designated as a Defined Service Area provided the county serves a monthly average of 400 or more individuals for receiving Long-Term Services and Supports.4. Multi-county service areas shall also be required to serve a minimum number of individuals Members of 400.5. Case Management services shall be provided to Members by the Case Management Agency awarded the contract for the Member's county of residence.6. Each Case Management Agency shall have an exceptions process and policy for serving Members outside of their Defined Service Area and for Members to request to be served by an Agency outside their service area. Each Case Management Agency shall submit the exceptions process and policy to the Department for approval by a method determined by the Department and shall review the process and policy with the Community Advisory Committee and Governing Body at least once per contract period.7. When a Member in a Case Management Agency's defined serve area requests to transfer to a Case Management Agency outside the Member's Defined Service Area, the Case Management Agencies shall coordinate the transfer in accordance with transfer rules 8.7202.M. Case Management Agencies shall provide a report on their process and the number of Members served outside their Defined Service Area upon Department request.8.7200.ECase Management Agency Selection and Contracting1. Case Management Agency Competitive Procurement Process2. The Department shall select Case Management Agencies in accordance to applicable requirements of Title 24, Articles 101-112, C.R.S., and 1 CCR 101-9.3. Case Management Agency Contract a. Case Management Agency shall be bound to all requirements identified in the contract between the Agency and the Department including but not limited to quality assurance standards and compliance with the Department's rules and federal regulation applicable for Case Management Agencies and for all Long-Term Services and Supports programs.47 CR 03, February 10, 2024, effective 3/16/202447 CR 23, December 10, 2024, effective 12/30/2024