10 Colo. Code Regs. § 2505-10-8.7556

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

Section 10 CCR 2505-10-8.7556 - Wellness Education Benefit

8.7556.AWellness Education Benefit Eligibility

1. Wellness Education Benefit is a covered benefit available to Members enrolled Children's Home and Community Based Services (CHCBS) Waiver.

8.7556.BWellness Education Benefit Definitions

1. Article means a written document that contains text related to health or wellness topics that a Member receives.

2. Article Topic means a health and wellness topic that relates to helping a Member manage health- related issues, achieve goals on their Person-Centered Support Plan, and address topics of community living.

3. Mail means the mechanism by which the benefit is sent to the Member through the United States Postal Service.

4. Plain language means friendly and clear, with a direct, conversational tone and active voice. The information is organized in logical order for the reader. Paragraphs are one-topic and brief, and sentences are simple and short. Plain language includes using common, everyday vocabulary consistently across correspondence, with few multi-syllable words and few technical or bureaucratic words.

5. Service rendered means the Provider Agency has sent the Wellness Education Benefit.

6. Provider Agency means the entity contracted with the Department to distribute the Wellness Education Benefit.

7. Verified Address means an address that mail can be sent to and received by a Member.

8. Wellness Education Benefit is individualized educational materials designed to reduce the need for a higher level of care by offering educational materials that provide members and their families with actionable tools that can be used to prevent the progression of a disability, increase community engagement, combat isolation, and improve awareness of Medicaid services. The Wellness Education Benefit helps Members and their unpaid caregivers to obtain, process, and understand information that assists with managing health-related issues, promoting community living, and achieving goals identified in their Person-Centered Support Plan. Wellness Education Benefit services include varied topics such as engaging in community activities, nutrition, adaptive exercise, balance training and fall prevention, money management, and developing social networks.

8.7556.CWellness Education Benefit Inclusions

1. The Wellness Education Benefit shall be delivered to the Member's mailing address in a printed format.

2. Article topics can provide the information needed to: Navigate the Medicaid/medical system to achieve better health outcomes, successfully manage chronic conditions in order to decrease risk of nursing facility placement, effectively communicate health and wellness goals, effectively communicate with medical and social service professionals, provide unpaid caregivers with relevant information regarding best practices around support and care of the Member, achieve community living goals identified in the Person-Centered Support Plan by providing simple, actionable suggestions to help support the health and welfare of waiver Members.

3. Article topics shall be written in plain language.

4. The Wellness Education Benefit is delivered no less than once every month, with a maximum of 12 unique education materials per year.

5. Wellness Education Benefit shall be provided in a format that is accessible to the Member at the request of the Member and their support team including, but not limited to, preferred written language. For Members who cannot read standard print and would benefit from an alternative format, educational materials will be sent to Members in the requested accessible format, which may include larger print or braille.

8.7556.DWellness Education Benefit Restrictions and Exclusions

1. Additional wellness reading materials, software, or subscriptions are excluded from the Wellness Education Benefit.

2. Article topics that do not address community living, Medicaid navigation, health-related issues, health care needs, mental health-related issues, or Person-Centered Support Plan goals shall be excluded from this benefit.

3. The Wellness Education Benefit does not duplicate services found in Early and Periodic Screening, Diagnostic, and Treatment.

8.7556.EWellness Education Benefit Provider Requirements

1. Provider Agencies must be contracted with the Department to distribute the Wellness Education Benefit.

2. Wellness Education Benefit Provider Agency shall be responsible for the following tasks:

a. Receive and manage member data in compliance with all applicable Health Insurance Portability and Accountability Act (HIPAA) regulations and ensure Member confidentiality and privacy.

b. Translate materials into select languages, as directed by the Department.

c. Both the Department and Wellness Benefit Provider Agency shall ensure that professionally certified translators and reviewers complete article translations and that translations are linguistically accurate and consistent with the formatting and technical specifications of the original document. Translations will be reviewed for cultural appropriateness before delivery.

d. Ensure that materials are Person-Centered and are formatted in an accessible format, which may include Braille, large print, or high contrast formats.

e. Maintain records of articles sent to members to prevent duplication of materials.

f. Conduct member outreach to gather information on how the service has helped Members thrive in the community and meet their health and wellness goals.

g. Utilize information on the Member's Person-Centered Support Plan and updated health conditions to guide the subject matter of the educational materials.

h. Identify any undeliverable Member addresses prior to each monthly mailing and manage any returned mail by sending the Department electronic, custom-formatted relevant address information. The Department will coordinate with case managers to update the Member's address and send updated addresses to the Provider Agency.

i. Verify Member addresses data files through the United States Postal Service "National Change of Address" database and identify any addresses that are undeliverable by USPS.

i. The Department will be informed by the Wellness Education Benefit Provider Agency of the educational materials that are undeliverable or returned to sender. An attempt to deliver the following month's service will take place using the following procedure:

1) The Department will notify the Member's Case Management Agencies of any returned or undeliverable mail.

2) Case Management Agencies shall update addresses in accordance with Department guidance.

8.7556.FWellness Education Benefit Provider Reimbursement Requirements

1. The Wellness Education Benefit is reimbursed based on the number of units of service provided, with one unit equal to one Article.

2. The Wellness Education Benefit will be delivered once every month, for twelve (12) units.

a. The Case Manager may authorize up to 12 additional units per support plan year for the following:

i. The Wellness Education Benefit was returned to sender as a non-deliverable, and the address is updated in time for the second round of monthly delivery.

ii. A Member has requested reasonable accommodation for an alternative format, such as braille.

iii. A Member requests that their representative receives a copy of the benefit to help them better utilize information provided in the benefit.

3. The annual total units that may be authorized for the Wellness Education Benefit shall not exceed 24 units per plan year.

8.7556.GWellness Education Benefit Case Management Agency Responsibilities

1. Wellness Education Benefit Introduction and Education:

a. The Case Manager shall provide Member information on the benefits of the Wellness Education Benefit, the types of articles included, and the frequency of delivery.

b. Through the person-centered planning process, the Case Manager will determine a format that is accessible to the Member including, but not limited to, preferred written language.

2. Case Management Agencies shall update addresses in accordance with Department guidance.

3. The Member may work with their Case Manager to request different subject matter for the educational materials.

4. The Case Manager may work with the Provider Agency to ensure the educational materials are being targeted to meet any new needs the Member may have.

5. Disenrollment

a. If a Member wants to opt out of the service, the Case Manager shall inform the Member of the possible implications of disenrollment. If a Member disenrolls, the Case Manager must revise the Prior Authorization Request to end-date the Wellness Education Benefit.

b. The Wellness Education Benefit is recognized as an HCBS service as it relates to Section 8.7101.35 and may be utilized to maintain waiver eligibility.

c. If services are decreased without the member's agreement, the Case Manager shall notify the Member of the adverse action and of appeal rights, according to Long-Term Care Waiver Program Notice of Action (LTC-803) regulations at Section 8.7206.18.

10 CCR 2505-10-8.7556

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

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