10 Colo. Code Regs. § 2505-10-8.7545

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

Section 10 CCR 2505-10-8.7545 - Adult Respite

8.7545.AAdult Respite Eligibility

1. Adult Respite is a covered benefit available to Members enrolled in one of the following HCBS waivers:

a. Brain Injury Waiver

b. Community Mental Health Supports Waiver

c. Complementary and Integrative Health Waiver

d. Elderly, Blind, and Disabled Waiver

e. Supported Living Services Waiver

8.7545.BAdult Respite Definition

1. Adult Respite care means services provided to an eligible Member on a short-term basis because of the absence or need for relief of those persons who normally provide the care.

8.7545.CAdult Respite Inclusions

1. HCBS Elderly, Blind, Disabled (EBD) Waiver; Complementary and Integrative Health (CIH) Waiver; Community Mental Health Supports (CMHS) Waiver

a. A nursing facility shall provide all the skilled and maintenance services ordinarily provided by a nursing facility which are required by the individual respite Member, as ordered by the physician.

b. An Alternative Care Facility shall provide all the Alternative Care Facility services as listed at Section 8.7506, which are required by the individual respite Member.

c. Respite may be provided in the Member's home, the home of the respite provider, or in the community.

2. HCBS Brain Injury (BI) Waiver

a. A nursing facility shall provide all the skilled and maintenance services ordinarily provided by a nursing facility which are required by the individual respite Member, as ordered by the physician.

b. Respite may be provided in the Member's home, home of the respite provider, or in the community.

3. HCBS Supported Living Services (SLS) Waiver

a. Respite may be provided in the Member's home;

b. The private residence of a respite care provider; or

c. In the community.

8.7545.DAdult Respite Exclusions and Limitations

1. HCBS Elderly, Blind, Disabled (EBD) Waiver; Complementary and Integrative Health (CIH) Waiver; Community Mental Health Supports (CMHS) Waiver

a. An individual Member shall be authorized for no more than (30) days of respite care in each support plan year unless otherwise authorized by the Department.

b. Alternative care facilities shall not admit individuals for respite care who are not appropriate for alternative care facility placement, as specified at 8.7506.

c. Only those portions of the facility that are Medicaid certified for nursing facility or alternative care facility services may be utilized for respite Members.

2. HCBS Brain Injury (BI) Waiver

a. An individual Member shall be authorized for no more than a cumulative total of 30 days of respite care in each certification period unless otherwise authorized by the Department. This total shall include respite care provided in both the home and in a nursing facility.

i. A mix of delivery options is allowable if the aggregate amount of services is less than 30 days, or 720 hours, of respite care.

ii. In-home respite is limited to no more than eight hours per day.

iii. Nursing facility respite is billed on a per diem.

iv. Only those portions of the facility that are Medicaid certified for nursing facility services may be utilized for respite Members.

3. HCBS Supported Living Services (SLS) Waiver

a. Overnight group respite may not substitute for other services provided by the provider such as personal care, behavioral services or services not covered by the HCBS-SLS Waiver.

b. Respite shall be reimbursed according to a unit rate or daily rate, whichever results in lesser reimbursement.

8.7545.EAdult Respite Provider Agency Requirements

1. HCBS Elderly, Blind, Disabled (EBD) Waiver; Complementary and Integrative Health (CIH) Waiver; Community Mental Health Supports (CMHS) Waiver

a. Respite care standards and procedures for nursing facilities are as follows:

i. The nursing facility must have a valid contract with the State as a Medicaid certified nursing facility. The contract shall constitute automatic Certification for respite care. A respite care provider billing number shall automatically be issued to all certified nursing facilities.

ii. The nursing facility does not have to maintain or hold open separately designated beds for respite Members but may accept respite Members on a bed available basis.

iii. For each HCBS-BI/EBD/CIH/CMHS respite Member, the nursing facility must provide an initial nursing Assessment, which will serve as the plan of care, must obtain physician treatment orders and diet orders; and must have a chart for the Member. The chart shall identify the Member as a respite Member. If the respite stay is for 14 days or more, the Minimum Data Set (MDS) shall be completed.

iv. An admission to a nursing facility under HCBS-BI/EBD/CIH/CMHS respite does not require a new Level of Care Screen, Pre-Admission Screening and Resident Review (PASRR) review, an AP-5615 form, a physical, a dietitian Assessment, a therapy Assessment, or lab work as required on an ordinary nursing facility admission. The MDS does not have to be completed if the respite stay is shorter than 14 days.

v. The nursing facility shall have written policies and procedures available to staff regarding respite care Members. Such policies could include copies of these respite rules, the facility's policy regarding self-administration of medication, and any other policies and procedures which may be useful to the staff in handling respite care Members.

vi. The nursing facility shall obtain a copy of the Level of Care Screen and the approved Prior Authorization Request (PAR) form from the Case Manager prior to the respite Member's entry into the facility.

b. Respite care standards and procedures for alternative care facilities are as follows:

i. The alternative care facility shall have a valid contract with the Department as a Medicaid certified HCBS-EBD/CMHS Alternative Care Facility Provider Agency. Such contract shall constitute Certification for HCBS-BI/EBD/CIH/CMHS respite care.

ii. For each respite care Member, the Alternative Care Facility shall follow normal procedures for care planning and documentation of services rendered.

c. Individual respite care providers shall be employees of certified personal care agencies. Family Members providing respite services shall meet the same competency standards as all other providers and be employed by the certified Provider Agency.

2. HCBS Brain Injury (BI) Waiver

a. Respite care standards and procedures for nursing facilities are as follows:

i. The nursing facility must have a valid contract with the State as a Medicaid certified nursing facility. The contract shall constitute automatic Certification for respite care. A respite care provider billing number shall automatically be issued to all certified nursing facilities.

ii. The nursing facility does not have to maintain or hold open separately designated beds for respite Members but may accept respite Members on a bed available basis.

iii. For each HCBS-BI/EBD/CIH/CMHS respite Member, the nursing facility must provide an initial nursing assessment, which will serve as the plan of care, must obtain physician treatment orders and diet orders; and must have a chart for the Member. The chart must identify the Member as a respite Member. If the respite stay is for 14 days or longer, the MDS must be completed.

iv. An admission to a nursing facility under HCBS-BI/EBD/CIH/CHMS respite does not require a Level of Care Screen, a Pre-Admission Screening and Resident Review (PASRR) review, an AP-5615 form, a physical, a dietitian assessment, a therapy assessment, or lab work as required on an ordinary nursing facility admission. The MDS does not have to be completed if the respite stay is shorter than 14 days.

v. The nursing facility shall have written policies and procedures available to staff regarding respite care Members. The policies could include copies of these respite rules, the facility's policy regarding self-administration of medication, and any other policies and procedures which may be useful to the staff in handling respite care Members.

vi. The nursing facility shall obtain a copy of the Level of Care Screen and the approved Prior Authorization Request (PAR) form from the Case Manager prior to the respite Member's entry into the facility.

b. Individual respite care providers shall be employees of certified personal care agencies. Family Members providing respite services shall meet the same competency standards as all other providers and be employed by the certified Provider Agency

8.7545.FAdult Respite Provider Reimbursement Requirements

1. For the HCBS Brain Injury (BI); Elderly, Blind, and Disabled (EBD); Complementary and Integrative Health (CIH); and Community Mental Health Supports (CMHS) Waivers:

a. Respite care reimbursement to nursing facilities shall be as follows:

i. The nursing facility shall bill using the facility's assigned respite provider number, and on the HCBS-BI/EBD/CIH/CMHS claim form according to fiscal agent instructions.

ii. The unit of reimbursement shall be a unit of one day. The day of admission and the day of discharge may both be reimbursed as full days, provided that there was at least one full twenty-four-hour day of respite provided by the nursing facility between the date of admission and the date of discharge. There shall be no other payment for partial days.

iii. Reimbursement shall be the lower of billed charges or the average weighted rate for administrative and health care for Class I nursing facilities in effect on July 1 of each year.

iv. Respite care reimbursement to Alternative Care Facilities shall be as follows:

1) The unit of reimbursement shall be a unit of one day. The day of admission and the day of discharge may both be reimbursed as full days, provided that there was at least one full twenty-four-hour day of respite provided by the alternative care facility between the date of admission and the date of discharge. There shall be no other payment for partial days.

v. Reimbursement shall be the lower of billed charges; or the maximum Medicaid rate for alternative care services, plus the standard alternative care facility room and board amount prorated for the number of days of respite.

b. Individual respite providers shall bill according to a unit rate or daily institutional Nursing Facility rate, whichever is less.

c. The respite care provider shall provide all the respite care that is needed, and other HCBS-BI/EBD/CIH/CMHS services shall not be reimbursed during the respite stay.

d. There shall be no reimbursement provided under this section for respite care in Uncertified Congregate Facilities.

2. HCBS Supported Living Services (SLS) Waiver:

a. Respite shall be provided according to individual, overnight group, or group rates as defined below:

i. Individual: the Member receives respite in a one-on-one situation. There are no other Members in the setting also receiving respite services.

ii. Overnight Group: the Member receives respite in a setting which is defined as a facility that offers 24-hour supervision through supervised overnight group accommodations. The total cost of overnight group within a 24-hour period shall not exceed the respite daily rate.

iii. Group: the Member receives care along with other individuals, who may or may not have a disability. The total cost of the group rate within a 24-hour period shall not exceed the respite daily rate.

10 CCR 2505-10-8.7545

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

47 CR 21, November 10, 2024, effective 11/30/2024