Colorado – Appendix K

Waiver Title

Elderly, Blind and Disabled (HCBS-EBD) Community Mental Health Supports (HCBS-CMHS) Supported Living Services (HCBS-SLS) Brain Injury (HCBS-BI) Spinal Cord Injury (HCBS-SCI) Developmental Disabilities (HCBS-DD) Childrens Home and Community Based Services (CHCBS) Children with Life Limiting Illness (HCBS-CLLI) Childrens Extensive Supports (HCBS-CES) Childrens Habilitation Residential Program (HCBS-CHRP

Description of Emergency

The Department of Health Care Policy & Financing Office of Community Living (OCL) has prepared an Appendix K: Emergency Preparedness and Response for the Home and Community-Based Services (HCBS) waiver applications that include the Elderly, Blind, and Disabled (EBD), Community Mental Health Supports (CMHS), Supported Living Services (SLS), Brain Injury (BI), Spinal Cord Injury (SCI), Developmental Disabilities (DD), Childrens Home and Community Based Services (CHCBS), Children with Life Limiting Illness (CLLI), Childrens Extensive Supports (CES), Childrens Habilitation Residential Program (CHRP) in order to ensure the health, welfare, and safety of our waiver participants by making additional resources available and accessible, changing waiver administrations and operations, and formalizing emergency actions to curtail or diminish the COVID-19 virus impact on the state of Colorado. By preparing this amendment to the waiver in advance of the spread of the COVID-19 virus, early communication and protocols regarding necessary changes during this emergency can be delivered swiftly, comprehensively, and with required back-ups in place to all HCBS waiver clients, providers, advocacy groups, state agencies, and non-state or non-governmental contracted entities. The Department continues to collaborate and respond to federal, state, and local public and private partners, providers and facilities to ensure a minimal disruption of services for the 48,643 HCBS waiver clients. As of end of day March 24, 2020, there were nine hundred and twelve (912) presumptive positive cases of COVID19 in Colorado. Currently, state and local public health are working together, following federal guidance, to assess and test suspected cases, identify people who may have been exposed to cases, and determine the need for monitoring, isolation, quarantine, or other restriction of movement and activities. Colorado is taking an aggressive approach in testing suspected cases who may have milder illness and are not hospitalized. We will continue with this approach as long as we have the resources and capacity to do so. Also, a network of clinical laboratories throughout Colorado are participating in an additional testing program. The state is requesting immediate implementation of the waiver amendment to ensure optimal maintenance of HCBS waiver clients level of health, welfare and safety. For the HCBS waiver participants in the state of Colorado, the Department desires to initiate the necessary changes to the service delivery methods as detailed in section K-2 and K-3 to include the following: Temporarily exceed service limitations or requirements for amount, duration, and prior authorization to address health and welfare issues presented by the emergency; Temporarily expand setting(s) where services may be provided; Temporarily permit payment for services rendered by family caregivers or legally responsible individuals; Temporarily modify licensure or other requirements for settings where waiver services are furnished; Temporarily modify processes for level of care evaluations or re-evaluations; Temporarily allow all CMA required activities to be completed via phone or other technology-based method with HCBS members in accordance with HIPAA requirements; and Temporarily exclude Professional Medical Information Page (PMIP) from the initial LOC process for the leng

Start Date

10-03-20

End Date

10-09-20

Description of Transition Plan

Individuals will transition to their pre-emergency service plan as soon as they are able. Needs will be reassessed by Case Management Agency staff. Additional supports as required transitioning from Appendix K flexibility into ongoing service plans will be considered as needed

Area(s) Affected

Area Affected

statewide

Access and Eligibility

Increase Cost Limits

Temporarily waive the current cost limit of $40,552.29 for the CES waiver for individuals who are impacted by COVID-19 (CES). Temporarily waive the current cost limit of $52,938.31 for the SLS waiver for individuals who are impacted by COVID-19 (SLS).

Modify Targeting Criteria

The modification of targeting criteria would include the expansion to those children/youth who have a history of a Life Limiting Illness or history of enrollment onto the CLLI waiver, with a physicians attestation of also being immunocompromised for the duration of the State Disaster Plan (CLLI).

Services

Modify Scope or Coverage

Individuals who demonstrate a need for Home Delivered meals, outside of a change in life circumstance, will be able to utilize this service up to the maximum of two (2) meals per day. (SCI), (EBD), (CMHS), (BI), (SLS), (DD) Expand the medication reminder benefit to a Specialized Medical Equipment and Supplies (SMES) benefit. The definition is to allow the coverage of items necessary for life support, ancillary supplies, and equipment. This will allow SCI clients to obtain necessary personal protective equipment (PPE) when needed. (SCI) Temporarily allow members on the CMHS waiver to access the In-Home Respite service. (CMHS)

Exceed Service Limitations

The 365-day transition period cap for Home Delivered Meal services will be extended for individuals who are currently utilizing the service. (SCI), (EBD), (CMHS), (BI), (SLS), (DD) Relatives employed by an IHSS agency may provide over the forty (40) hours of personal care (up to forty-eight (48)) in a seven (7) day period. A family member who is an individuals authorized representative may be reimbursed for the provision of IHSS if the individuals personal care worker is unable to meet their personal care needs. (SCI), (EBD), (BI) The four (4) one-way trip services per week for Non-Medical Transportation may be exceeded depending on need. (SCI), (EBD), (CMHS), (BI) The number of units available for Transportation Services may exceed 508 units per Service Plan year. A unit is a per-trip charge for to and from Day Habilitation and Supported Employment programs. (SLS), (DD) Behavioral Services Counseling Services may exceed the current 208-unit limitation, as needed and identified by the behavioral consultant. (SLS), (DD) Behavioral Services Line Staff Services may exceed the current 960 units per service plan year based on need (SLS), (DD) Expressive Therapys, (Art and Play Therapy, and Music Therapy) maximum unit limitation may be exceeded when there is a demonstrated need. (CLLI) Therapeutic Services (Bereavement Counseling, Therapeutic Life Limiting Illness Support for Individual, Group or Family) maximum unit limitation may be exceeded when there is a demonstrated need. (CLLI) Respite Care maximum of thirty (30) days or unit limitations may be exceeded when there is a demonstrated need. (CES), (SCI), (EBD), (CMHS), (BI), (SLS), (CHRP), (CLLI) Special Medical Equipment and Supplies (SMES) unit maximums may be exceeded when there is a demonstrated need due to COVID-19. All medically necessary items that are covered under the Durable Medical Equipment or EPSDT benefit within the state plan shall be accessed first. (CES), (SCI), (EBD), (CMHS), (BI), (SLS), (DD) Youth Days ten (10) hour maximum limitation may be exceeded when there is a demonstrated need. (CES) CDASS: Relative CDASS attendants may provide over the forty (40) hours of personal care in a seven (7) day period up to forty-eight (48) at this time. Requirements will be waived for a client to switch to agency-based care if a CDASS attendant cannot be in found. The Department may permit a client to receive both CDASS services and agency-based services or State Plan Long-Term Home Health (LTHH) if a CDASS attendant cannot be found. The Department will ensure that there is no duplication of consumer directed and agency-based services by reviewing the CDASS members timesheets. CDASS members will maintain time sheets to ensure no duplication of services. In addition, the Department will audit claims submitted for both services to ensure that duplication has not occurred. The Department will conduct training with CDASS attendants and agency-based providers to ensure that duplication of services does not occur. The Department will allow clients to exceed monthly budget caps and allocation caps, as necessary during the COVID-19 emergency period. (SCI), (EBD), (CMHS), (BI), (SLS) Support Plan Authorization Limits (SPAL): Individuals will be permitted to exceed the SPALs and overall spending limit as defined in Appendix C-4: Additional Limits on Amount of Waiver Services, when there is a demonstrated need documented in the case management system (SLS). Supported Community Connector unit limitations may be exceeded when there is a demonstrated need (CHRP). Day Habilitation: Maximum of 7,112 combined units of Specialized Habilitation, Supported Community Connections, Prevocational Services, and Supported Employment per Service Plan year may be exceed when there is a demonstrated need (DD, SLS).

Add Services

Service Definition (Scope): ALL Waivers A. Remote Support Services provide oversight and monitoring within the participants home through an off-site electronic support system in order to reduce or replace the amount of staffing a participant needs in accordance with HIPAA requirements. B. The purpose of Remote Support Services is to support the participant to exercise greater independence over their lives. It is integrated into the participants overall support system and reduces the amount of staff support a person uses in their home while ensuring health and welfare. C. Remote Support Service includes: 1. Electronic support system installation, repair, maintenance, and back-up system; 2. Training and technical assistance for the participant and his or her support network; 3. Off-site system monitoring staff; and 4. Stand-by intervention staff for notifying emergency personnel such as police, fire, and back-up support staff.

Expand Settings

ACF (EBD, CMHS) Adaptive Therapeutic Recreational Equipment and Fees (CES) Adult Day (SCI), (EBD), (CMHS), (BI) Assistive Technology (CES), (SLS) Behavioral Services (CHRP), (DD) Behavioral Management and Education (BI) Bereavement Counseling (CLLI) Expressive Therapy (CLLI) Community Connector (CES) Complementary and Integrative Health Services (SCI) Day Treatment (BI) Day Habilitation (SLS), (DD) Hippotherapy (CES) Home Delivered Meals (EBD), (CMHS), (SCI), (BI), (SLS), (DD) Home Modifications (SCI), (CES), (EBD), (CMHS), (BI), (SLS) Homemaker (CES), (SCI), (EBD), CMHS), (BI) Life Skills Training (SCI), (EBD), (CMHS), (BI), (SLS)IHSS (CHCBS), (SCI), (EBD) Independent Living Skills Training (BI) Intensive Supports (CHRP) PERS (SCI), (EBD), (CMHS), (SLS) Medication Reminder (SCI), (EBD), (CMHS) Massage (CES), (CHRP), (CLLI) Mental Health Therapy (BI) Mentorship (SLS) Movement Therapy (CES), (CHRP) Palliative/Supportive Care (CLLI) Peer Mentorship (SCI), (EBD), (CMHS), (BI), (SLS), (DD) Prevocational (SLS), (DD) Professional Services (SLS) Respite (SCI), (CES), (EBD), (CMHS), (BI), (SLS), (CHRP), (CLLI), (DD) Residential Services (CHRP) Residential Habilitation (DD) Supported Employment (SLS), (DD) Supported Community Connector (CHRP), (DD) Supported Living Programs (SLP)Substance Abuse Counseling (BI) Therapeutic Life Limiting Illness Support (CLLI) Transition Set-Up and Coordination (SCI), (EBD), (CMHS), (BI), (SLS) Transitional Living Programs (TLP)Transition Support (CHRP) Youth Day Services (CES) The above services when feasible may be delivered temporarily through virtual means in the participants residential setting or other Department identified locations to ensure the clients health, safety, and welfare in accordance with HIPAA requirements. This could include: The participants private home; A provider owned or controlled or extended family home; Community center or designated community gathering center; Hotel/paid lodging; Newly rented room; or Other residential setting. Room and board is not currently included within the respite rate. If respite is required in a non-traditional setting (i.e. hotel), the Department may need to include amounts in addition to the base rate in order to account for room and board outside of the clients regular cost to the existing residential provider. Professional evaluations for the Home Accessibility and Adaptations, Vehicle Modifications, and Assistive Technology benefits may be completed virtually when the client has live video sharing capabilities with the professional in accordance with HIPAA requirements.

Provide Service Out of State

N/A

Allow Payment for Services by Families

Allow relatives, spouses, and legally responsible persons to provide: CDASS (SCI), (EBD), (CMHS), (BI), (SLS) Community Connector (CES) Day Habilitation (SLS), (DD) Homemaker (SCI), (EBD), (CMHS), (BI) IHSS (SCI), (CHCBS), (EBD) Mentorship (SLS) Peer Mentorship (SLS), (DD) Personal care (SCI), (EBD), (CMHS), (BI), (SLS) Respite (SCI), (CES), (EBD), (CMHS), (BI), (SLS), (CHRP), (CLLI) Residential (CHRP) Residential Habilitation (DD) Supported Community Connector (CHRP) Youth Day (CES) The Department will apply the following safeguards to ensure individuals receive necessary services authorized through the care plan: case management monitoring and post payment review of claims paid.

Modify Provider Qualifications

Modification of Provider Qualifications

The Department will review any request to waive caregiver age from (18) to (16) for the following services on a case-by-case basis. CDASS (SCI), (EBD), (CMHS), (BI), (SLS) Homemaker (SCI), (CES), (EBD), (CMHS), (BI), (SLS) IHSS (SCI), (CHCBS), (EBD), Personal Care (SCI), (EBD), (CMHS), (BI), (SLS) When necessary, allow the Authorized Representative (AR) to also be the care attendant for CDASS. Waive training requirements for new CDASS Authorized Representatives.

Modify Provider Types

Any licensed professional with the relevant training and associated licensure through the Colorado Department of Regulatory Agencies (DORA) that provides professional services through the State Plan will be temporarily permitted to provide services to HCBS waiver participants, applicable to: Behavioral management and Education (BI) Behavioral Services (SLS), (DD) Bereavement Counseling (CLLI) Complementary and Integrative Health Services (SCI) Expressive Therapy (CLLI) Independent Living Skills Training (BI) Intensive Support (CHRP) Massage Therapy (CES), (SLS), (CHRP), (CLLI) Mental Health Therapy (BI) Movement Therapy (CES), (SLS), (CHRP) Parent Education Services (CES) Substance Abuse Counseling (BI) Therapeutic Life Limiting Illness Support services (CLLI) Any licensed Home Care Agency or Hospice Agency that provides services through the State Plan is temporarily permitted to provide skilled and unskilled services through the waiver to HCBS participants, applicable to: Adult Day (SCI), (EBD), (CMHS), (BI) Day Treatment (BI) Homemaker (SCI), (EBD), (CMHS), (BI), (SLS) IHSS (SCI), (CHCBS), (EBD), Independent Living Skills Training (BI) Life Skills Training (SCI), (EBD), (CMHS), (BI) Massage Therapy (CES) Movement Therapy (CES) Parent Education (CES) Palliative and Supportive Care Services (CLLI) Peer Mentorship (SCI), (EBD), (CMHS), (BI), (DD), (SLS) Personal Care (SCI), (EBD), (CMHS), (BI), (SLS) Respite (SCI), (EBD), (CMHS), (BI), (SLS), (CHRP), (CLLI) Any licensed Home Care agency providing HCBS services is temporarily permitted to provide services outside of their enrolled specialties, to include but not limited to: Adult Day (SCI), (EBD), (CMHS), (BI) Community Connector (CES) Day Treatment (BI) Day Habilitation (SLS), (DD) Health Maintenance (SLS) Homemaker (SCI), (CES), (EBD), (CMHS), (BI), (SLS) Life Skills Training (SCI), (EBD), (CMHS), (BI), (SLS) Independent Living Skills Training (BI) Mentorship (SLS) Non-Medical Transportation (SCI), (EBD), (CMHS), (BI), (SLS), (DD) Peer Mentorship (SCI), (EBD), (CMHS), (BI), (SLS), (DD) Personal Care (SCI), (EBD), (CMHS), (BI), (SLS) Respite (SCI), (CES), (EBD), (CMHS), (BI), (SLS), (CHRP), (CLLI) Transition Set-Up and Coordination (EBD), (SCI), (CMHS), (BI), (SLS), (DD) Youth Day (CES) The Department has expanded the provider type for Home Delivered Meals to include: Hospitals; Schools; Restaurants; Home Health Agency; Senior Center; Social Service Agency; Church; and Any Entity Providing Home Delivered Meals. (SCI), (EBD), (CMHS), (BI), (SLS), (DD)

Modify Licensure/Requirements for Waiver Settings

State certification survey staff are, on a case-by-case basis, postponing agency certification and licensure reviews for services that are surveyed by the Department of Public Health and Environment, Health Facilities and Emergency Section Division until the area is no longer in a state of emergency. This is for the safety of the survey staff and individuals who are utilizing these services. Certification and licensure surveys will be conducted for abuse and neglect complaints, immediate jeopardy concerns, as well as new licensure and certification requests for new providers

Modification LOC Eval and Re-Eval Processes

The Department is requesting the ability to increase, supplement, or provide additional fee-forservice payment(s) to all HCBS providers, to ensure continuity of operations and assurance of client health, safety, and welfare within waiver benefits. The Department requests the ability to pay 8% enhanced rates to the following services: Adult Day Services (SCI), (EBD), (CMHS), (BI) Adult Day Service Transportation (SCI), (EBD), (CMHS), (BI) Adaptive Therapeutic Recreational Equipment and Fees (CES) Assistive Technology (CES), (SLS) Behavioral Management and Education, Day Treatment (BI) Behavioral Services (SLS), (CHRP), (DD) Community Connector (CES) Complementary and Integrative Health Services (SCI) Consumer Directed Attendant Support Services (SCI), (EBD), (CMHS), (BI), (SLS) Day Treatment (BI) Day Habilitation (SLS), (DD) Expressive Therapy (Art and Play Therapy and Music Therapy) (CLLI) Dental (SLS), (DD) Hippotherapy (CES) Homemaker (SCI), (CES), (EBD), (CMHS), (BI), (SLS) Home Delivered Meals (SCI), (EBD), (CMHS), (BI), (SLS), (DD) Home Modification (SCI), (EBD), (CMHS), (BI), (SLS) In-Home Support Services (SCI), (CHCBS), (EBD) Intensive Support Services (CHRP) Life Skills Training (SCI), (EBD), (CMHS), (BI), (SLS) Massage therapy (CES), (CLLI) Medication Reminder (EBD), (CMHS), (BI) Mental Health Therapy (BI) Mentorship (SLS) Movement Therapy (CES) Non-Medical Transportation (SCI), (EBD), (CMHS), (BI), (SLS), (DD) Palliative and Supportive Care (Care Coordination and Pain and Symptom Management (skilled)) (CLLI) Peer Mentorship (SCI), (EBD), (CMHS), (BI), (SLS), (DD) Personal Care (SCI), (EBD), (CMHS), (BI), (SLS) Prevocational Services (SLS), (DD) Personal Emergency Response Systems (SCI), (EBD), (CMHS), (BI), (SLS) Professional Services (SLS), (CHRP) Respite (SCI), (CES), (EBD), (CMHS), (BI), (SLS), (CHRP), (CLLI) Specialized Medical Equipment and Supplies (SCI), (EBD), (CES), (CMHS), (BI), (SLS), (DD) Substance Abuse Counseling (BI) Supported Community Connector (SLS) Supported Employment (SLS), (DD) Transition Supports (CHRP) Transition Set-Up and Coordination (SCI), (EBD), (CMHS), (BI), (SLS) Therapeutic Services (Bereavement Counseling, Therapeutic Life Limiting Illness Support Individual, Group and Family) (CLLI). Vehicle Modification (CES), (SLS) Vision (SLS), (DD) Youth Day (CES) The Department requests the ability to pay a 13% enhanced rate for the following services: Alternative Care Facility (EBD), (CMHS) Residential Services (CHRP) Residential Habilitation (DD) Supported Living Programs (BI) Transitional Living Programs (BI) Depending on the need, the rates may need to exceed the currently approved rate methodology as delineated in this amendment. The Department has attached the current rate sheet.

Increase Payment Rates

Modifications of ISP

N/A

Modify Incident Reporting/Med Management Safeguards

In the circumstance individuals in services must evacuate their current setting, the Department would develop processes to ensure the health, safety, and welfare of the client but would allow for additional flexibility in location and timeliness of reporting due to the emergent need.

Allow Payment for Services During Acute Care Hospital/Short Term Institutional Stay

CDASS, IHSS, and Personal Care services may be provided in an acute setting, when the service is not able to be provided by the Acute Setting provider not to exceed 30 days consecutively. There Department will ensure no duplication of services through documentation of tasks provided and a waiver form completed by the acute setting staff attesting that specific tasks needed in the acute care hospital or short-term institutional stay cannot be done by the facility staff due to system capacity or other critical service interruption and that the participant may have a trained attendant complete the specific tasks.

Inclusion of Retainer Payments

Retainer payments for services that include Personal Care including Adult Day Centers, Habilitation Services (Specialized Habilitation, Supported Community Connections, PreVocational Services, Supported Employment Services, and Community Connector), and Personal Care Services shall be provided in response to the impact of the COVID-19 pandemic on certain Medicaid providers and shall not exceed the total amount that the provider would have received had services been provided as expected. The retainer time limit may not exceed the lesser of 30 consecutive days or the number of days for which the State authorizes a payment for bedhold in nursing facilities.

Institute/Expand Opportunities for Self-Direction

N/A

Increase Factor C

N/A

Other Changes Necessary

Temporarily allow HCBS members to receive one service per month for the length of the State Disaster Plan without being subject to discharge via telephonically or monthly monitoring by telehealth in accordance with HIPAA requirements. Temporarily allow all CMA required face-to-face activities to be completed via phone or other technology-based methods with HCBS members in accordance with HIPAA requirements.

Addendum

HCBS Regulations

Not comply with the HCBS settings requirement at 42 CFR 441.301(c)(4)(vi)(D) that individuals are able to have visitors of their choosing at any time, for settings added after March 17, 2014, to minimize the spread of infection during the COVID-19 pandemic.

Services

Add Electronic Method of Service Delivery

N/A

Add Home Delivered Meals

N/A

Add Medical Supplies, Equipment and Appliances

N/A

Add Assistive Technology

N/A

Conflict of Interest

Other Changes Necessary

Provider Qualifications

Allow Spouses and Parents of Minor Children to Provide Personal Care Servcies

N/A

Allow a Family Member to be Paid to Render Services to an Individual

N/A

Allow Other Practitioners in Lieu of Approved Providers Within the Waiver

N/A

Modify Service Providers for Home-Delivered Meals to Allow for Additional Providers, Including Non-Traditional Providers

N/A

Processes

Allow an Extension for Reassessments and Reevaluations for up to One Year Past the Due Date

N/A

Allow the Option to Conduct Evaluations, Assessments, and Person-Centered Service Planning Meetings Virtually/Remotely in lieu of Face-to-Face Meetings

N/A

Adjust Prior Approval/Authorization Elements Approved in Waiver

N/A

Adjust Assessment Requirements

N/A

Add an Electronic Method of Signing Off on Required Documents Duch As The Person-Centered Service Plan

N/A

Link To Application

Colorado Appendix K - Link to Application (PDF)

Link to Approval Letter

Colorado Appendix K - Link to Approval Letter (PDF)