Home and Community Based Services (HCBS) Brain Injury (BI), Community Mental Health Supports (CMHS) and Elderly, Blind and Disabled (EBD)

• General Information
• Prior Authorization Requests (PARs)
• PAR Submission
• Consumer Directed Attendant Support Services (CDASS)
• PAR Form Instructional Reference Table
• Claim Submission
• Persons with a Brain Injury (HCBS-BI)
• HCBS-BI Procedure Code Table
• HCBS-BI Paper Claim Reference Table
• Community Mental Health Supports (CMHS), and Persons who are Elderly, Blind and Disabled (EBD)
• HCBS-CMHS Procedure Code Table
• HCBS-EBD Procedure Code Table
• HCBS-CMHS and EBD Paper Claim Reference Table
• Timely Filing
• HCBS-BI, CMHS and EBD Specialty Manuals Revisions Log

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General Information

Waiver programs provide additional Health First Colorado (Colorado's Medicaid program) benefits to specific populations who meet special eligibility criteria.

Level of care determinations are made annually by the case management agencies (aka Single-Entry Points). Members must meet financial, medical, and program criteria to access services under a waiver. The applicant must be at risk of placement in a nursing facility or hospital. To access waiver benefits, members must be willing to receive services in their homes or communities. A member who receives services through a waiver is also eligible for all basic Health First Colorado covered services except nursing facility and long-term hospital care. When a member chooses to receive services under a waiver, the services must be provided by certified Health First Colorado providers.

Applicants may apply for more than one waiver but may only receive services through one waiver at a time.

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Prior Authorization Requests (PARs)

Unless otherwise noted, all HCBS services require prior approval before they can be reimbursed by Health First Colorado. Case management agencies/single entry points complete the Prior Approval and/or Cost Containment requests for their specific programs according to instructions published in the regulations for the Department of Health Care Policy & Financing (the Department).

Refer to Appendix A located on the Billing Manuals web page under the Appendices drop-down for telephone numbers.

The following services have additional state approval processes beyond the PAR:

• Services above the daily cost containment limit
• Home modifications
• Mental health counseling (beyond 30 visits),
• Substance Abuse Counseling (beyond 30 visits)

Assistive Technology (beyond medication reminders). Providers may contact the CMA/SEP for the status of the PAR or inquire electronically through the Health First Colorado Online Portal.

The CMAs/SEPs responsibilities include, but not limited to:

• Informing members and/or legal guardian of the eligibility process.
• Submitting a copy of the approved Enrollment Form to the County department of human/social services for a Health First Colorado member identification number.
• Developing the appropriate Prior Approval and/or Cost Containment Record Form of services and projected costs for approval.
• Submitting the Prior Authorization and/or Cost Containment information to the authorizing agent. Refer to Appendix D located on the Billing Manuals web page under the Appendices drop-down for a list of authorizing agents.
• Assessing the member's health and social needs.
• Arranging for face-to-face contact with the member within 10 calendar days of receipt of the referral.
• Monitoring and evaluating services.
• Reassessing each member.
• Demonstrating continued cost effectiveness whenever services increase or decrease.

Approval of prior authorization does not guarantee Health First Colorado payment and does not serve as a timely filing waiver. Prior authorization only assures that the approved service is a medical necessity and is considered a benefit of the Health First Colorado. All claims, including those for prior authorized services, must meet eligibility and claim submission requirements (e.g., timely filing, provider information completed appropriately, required attachments included, etc.) before payment can be made.

Prior approvals must be completed thoroughly and accurately. If an error is noted on an approved request, it should be brought to the attention of the member's case manager for corrections. Procedure codes, quantities, etc., may be changed or entered by the member's case manager.

The authorizing agent or case management agency/single entry point is responsible for timely submission and distribution of copies of approvals to agencies and providers contracted to provide services.

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PAR Submission

The HCBS-BI, CMHS, and EBD forms are submitted electronically via the Bridge by CMA/SEP case managers. The Bridge directly interfaces with the Colorado interChange System. Access to the Bridge is accomplished via the Medicaid Enterprise User Provisioning System (MEUPS).

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Consumer Directed Attendant Support Services (CDASS)

For members authorized to receive CDASS, case managers will need to enter the data into one of the web-based systems in addition to sending a PAR to the Department's fiscal agent. Members have the option to receive Financial Management Services (FMS) from one (1) of two (2) FMS vendors:

• Palco
• Public Partnerships, LLC (PPL)

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PAR Form Instructional Reference Table

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Claim Submission

Submission of claims for services rendered must not be duplicative. Providers cannot be reimbursed for delivering the same service to the same member on the same day at the same time, whether such services are billed on the same claim or on multiple/different claims. Additionally, providers are barred from billing services that share or have overlapping service definitions but are described by different procedure codes on the same day to the same member. Collectively referred to as duplicate claims, reimbursement for such claims requires clear documentation of the necessity of the service and that there was not duplicative service delivery. 

Refer to the service definitions on the Colorado Code of Regulations website to identify if claims are duplicative based on services rendered. Refer to the provider specialty code enrollment requirements on the HCBS Provider Specialty Code List web page to identify services that may be provided by an individual provider. Providers may only bill for services approved in Members’ service plans.

In any instance in which duplicate claim submission results in Medicaid reimbursement, the Department has the authority to recoup funds from providers.

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down menu for general billing information, including claims submission.

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Persons with a Brain Injury (HCBS-BI)

The Home and Community Based Services Brain Injury (HCBS-BI) waiver program provides a variety of services to qualified members with brain injury as an alternative to inpatient hospital and nursing facility placement. Members meeting program eligibility requirements are certified as medically eligible for HCBS-BI by the case manager.

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HCBS-BI Procedure Code Table

Providers may bill the following procedure codes for HCBS-BI services:

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Paper Claim Reference Table

The following paper form reference table gives required and/or conditional fields for the paper CMS 1500 claim form for BI claims:

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Community Mental Health Supports (CMHS) and Persons Who are Elderly, Blind and Disabled (EBD)

The HCBS-CMHS and EBD waiver programs provide a variety of services to the Elderly, Blind and Disabled (EBD), and Community Mental Health Supports (HCBS-CMHS), formally known as Persons with Major Mental Illness (MI), as an alternative to nursing facility, and inpatient hospitals to qualified members. Members meeting program eligibility requirements are certified by the case management agency/single entry point as medically eligible for these HCBS waiver programs. These three waivers offer all of the following services:

• Alternative Care Facility - Alternative Care Services means, but is not limited to, a package of personal care and homemaker services provided in a state-certified alternative care facility including assistance with bathing, skin, hair, nail and mouth care, shaving, dressing, feeding, ambulation, transfers, and positioning, bladder and bowel care, medication reminding, accompanying, routine housecleaning, meal preparation, bed making, laundry and shopping. Reimbursement shall be per unit, with one unit equaling one day of care.
• Adult Day Services (Basic) - Services delivered on a tiered basis.
  • Tier I - Services provided virtually or in-person in an outpatient setting to include parks or other community-based locations. Meal provision not required if services are not provided in person or over the lunch hour. Service can be provided up to three hours per day.
  • Tier II - Services provided between three (3) - five (5) hours per day as approved by the case manager and in the context of the member's health, for one or more days per week. Services provided in an outpatient setting, encompassing both health and social services needed to assure the optimal functioning of the individual. Meals provided as part of these services shall not constitute a full nutritional regimen" (3 meals per day). Physical, occupational and speech therapies indicated in the individual's plan of care would be provided as component parts of this service if such services are not being provided in the participant's home.
• Tier III - Services provided over a full day as approved by the case manager and in the context of the member's health, for one or more days per week. Services provided in an outpatient setting, encompassing both health and social services needed to assure the optimal functioning of the individual. Meals provided as part of these services shall not constitute a full nutritional regimen" (3 meals per day). Physical, occupational and speech therapies indicated in the individual's plan of care would be provided as component parts of this service if such services are not being provided in the participant's home. Tier I Adult Day Services cannot be provided in conjunction with this service.
• Adult Day Services (Specialized) - Services provided between three (3) - five (5) or more hours per day on a regularly scheduled basis, for one or more days per week. Services provided in an outpatient setting, encompassing both health and social services needed to assure the optimal functioning of the individual. Meals provided as part of these services shall not constitute a full nutritional regimen" (3 meals per day). Physical, occupational and speech therapies indicated in the individual's plan of care would be provided as component parts of this service if such services are not being provided in the participant's home. Tier I Adult Day Services cannot be provided in conjunction with this service.
• Electronic Monitoring (Personal Emergency Response Systems) - An electronic device, which enables certain individuals at high risk of institutionalization to secure help in an emergency. The individual may also wear a portable help" button to allow for mobility. The system is connected to the person's phone and programmed to signal a response center once a help" button is activated. Monitoring of the device is included in the PERS service. The response center is staffed by trained professionals.
• Electronic Monitoring (Medication Reminders) - Medication reminders are devices, controls, or appliances which enable an individual at high risk of institutionalization to increase their abilities to perform activities of daily living, such as medication administration. Medication reminders shall include devices or items that remind or signal the member to take prescribed medications. Medication reminders may include other devices necessary for the proper functioning of such items and may also include durable and non-durable medical equipment not available as a State plan benefit. 
• Homemaker - Services consisting of general household activities (meal preparation and routine household care) provided by a trained homemaker. Provided when the individual regularly responsible for these activities is temporarily absent or unable to manage the home and care for him or herself or others in the home.
• Home Modifications - Specific modifications, adaptations or improvements in an eligible member's existing home setting which, based on the member's medical condition are necessary to ensure the health, welfare and safety of the member, enable the member to function with greater independence in the home, are required because of the member's illness, impairment or disability, as documented on the ULTC-100.2 form and the care plan and prevents institutionalization of the member. There shall be a lifetime cap of $14,000.00 per member.
• Personal Care - Assistance with eating, bathing, dressing, personal hygiene, activities of daily living. These services may include assistance with preparation of meals but does not include the cost of the meals themselves. When specified in the service plan, this service may also include such housekeeping chores as bed making, dusting and vacuuming. Services are incidental to the care provided or are essential to the health and welfare of the individual, rather than the individual's family. Payment will not be made for services provided to a minor by the child's parent (or stepparent), or to an individual by the person's spouse.
• Relative Personal Care - Personal Care providers may be members of the individual's family. The number of Health First Colorado personal care units for provided by any single member of the member's family shall not exceed the equivalent of 444 personal care units per annual certification. Payment will not be made for services provided to an individual by an individual's spouse employed by a Personal Care agency.
• Respite care - Services provided to an eligible member on a short-term basis because of the absence or need for relief of those persons normally providing the care. The unit of reimbursement shall be a unit of one day for care provided in a Nursing Facility or Alternative Care Facility. Individual respite providers shall bill according to an hourly rate or daily institutional Nursing Facility rate, whichever is less.
• Non-Medical Transportation - Service offered in order to enable individuals served on the waiver to gain access to waiver and other community services, activities and resources, specified by the service plan. This service is offered in addition to medical transportation required under 42 CFR 431.53 and transportation services under the State Plan, defined at 42 CFR 440.170 (a) (if applicable), and shall not replace them.
  Non-Medical Transportation will be limited to two (2) roundtrips per week. Trips to and from adult day programs are not subject to this cap.
• Consumer Directed Attendant Support Services (CDASS) - CDASS is a service delivery option that offers HCBS-EBD, HCBS-CMHS, and HCBS-BI members the opportunity to direct personal care, homemaker and health maintenance tasks. Members may also designate an authorized representative to direct these activities on their behalf.
• Home Delivered Meals - Includes nutritional counseling, planning, preparation, and delivery of meals. Must demonstrate need for the service in Service Plan: demonstrated need for nutritional counseling, meal planning, and preparation, dietary restrictions or specific nutritional needs, unable to prepare their own meals, limited or no outside assistance, inability to access and prepare nutritious meals demonstrates a need-related risk to health, safety or institutionalization. Home Delivered Meals are limited to two (2) meals per day up to 14 meals per week, up to 365 days post-transition.
• A new expansion effective April 1, 2023, allows for home delivered meals following a 24hr hospitalization providing up to 30 days of meals post discharge two times within a certification period. Members have up to 30 days post discharge to opt in to receive this benefit.
• Life Skills Training - Individualized training, provided in member's residence, the community, or group living situations, that is designed and directed with member to develop and maintain the ability to independently sustain himself/herself in the community. Must demonstrate need for the service in Service Plan: need for training to sustain self in the community, skills for which training is needed and that without poses a risk to the health, safety, or ability to live in the community, without training individual could not develop the skills needed, with training ability to acquire these skills within 365 days. Life Skills Training is limited to up to 24 units per day with no more than 160 units per week, up to 365 days post-transition.
• Peer Mentorship - Provided by peers to promote self-advocacy and encourage community living by instructing and advising on issues and topics related to community living, describing real-world experiences as examples, and modeling successful community living and problem-solving. Must demonstrate the need for the service in Service Plan: need for soft skills, insight, or guidance from a peer, without service may experience a health, safety, or institutional risk, no other services or resources available to meet the need. Peer Mentorship is limited to 24 units per day for 365 days post-transition.
• Remote Supports - Remote Supports service provides live, two (2)-way virtual coaching, supervision and cues from a virtual attendant for everyday activities of daily living that do not require hands-on assistance to be completed safely. These supports can help a member live more independently in their home and community. Services may include prompts and reminders for such needs as dressing, cooking support, overnight support and fall detection. Remote Supports Technology is included to purchase and install devices that support the delivery of Remote Supports.
• Transition Setup - Coordination and coverage of one-time, non-recurring expenses to establish a basic household upon transition from nursing facility, Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), or Regional Center to a community living arrangement not operated by the state. 
  Note: This is not available for transition to provider-owned settings (e.g., ACF, Host Home, Group Home, or SLP. This is not available in a community-to-community transition.] Units limited to 40, up to 30 days post-transition.

The HCBS-EBD program offers the following additional services:

• In-Home Support Services (IHSS) - IHSS includes health maintenance activities, support for activities of daily living or instrumental activities of daily living, personal care service and homemaker services. Additionally, IHSS providers are required to provide the core independent living skills. This service is only available for EBD, CIH (formerly SCI) and CHCBS members.

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HCBS-CMHS Procedure Code Table

Providers may bill the following procedure codes for HCBS-CMHS services:

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HCBS-EBD Procedure Code Table

Providers may bill the following procedure codes for HCBS-EBD services:

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HCBS-CMHS and EBD Paper Claim Reference Table

The following paper form reference table gives required and/or conditional fields for the paper CMS 1500 claim form for HCBS-CMHS and HCBS-EBD claims:

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Timely Filing

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down for more information on timely filing policy, including the resubmission rules for denied claims.

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HCBS-BI, CMHS and EBD Specialty Manuals Revisions Log

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