Case Management Redesign

Q: What is Case Management Redesign (CMRD)?  

A: Case Management Redesign refers to several initiatives that will help make accessing long-term services and supports (LTSS) easier by changing case management agencies to serve all Home and Community-Based Service (HCBS) waivers so people have one place to go, making sure there are the right number of case management agencies in Colorado, and increasing the quality of case management services.

  
Q: Why is CMRD happening?  

A: Single Entry Points (SEPs), Community Centered Boards (CCBs), and private Case Management Agencies currently provide case management for individuals with disabilities in the Colorado Department of Health Care Policy and Financing’s (HCPF) ten HCBS waiver programs, with each serving different waiver programs.  

In addition to case management services, many Case Management Agencies (CMAs) also provide direct services to program recipients, creating a conflict of interest which is no longer allowable by the Centers for Medicare and Medicaid Services (CMS). 

Individuals who are seeking or receiving LTSS often qualify for multiple programs and end up navigating between systems that are siloed by program, making the system difficult for members.  

CMRD is intended to simplify access and remove silos so members will be able to more easily navigate and find the right programs and services that work for them. It will require one case management agency to provide case management services for all waiver programs in each defined service area that is awarded by HCPF through a competitive procurement process.

Further, these changes will meet the federal Conflict-Free Case Management requirement and allow HCPF to ensure quality case management services for members across the state.

  
Q: Why is CMRD happening NOW?  

A: In 2014, CMS, HCPF’s federal partner, released the requirements for the “HCBS Settings Final Rule.” It included many requirements for providers to make changes to their processes to increase person-centeredness.   

This rule also included a requirement for case management agencies to be “conflict-free,” which means that they cannot provide services to the same person they are providing case management services to. Colorado must come into compliance with these rules by July 1, 2024.

Q: What if we don’t implement CMRD?  

A: If Colorado does not come into compliance with conflict-free case management, the risk is losing federal funding, which is 50% of the budget for home and community-based services. This would be detrimental to people in Colorado being able to access these vital services in the future. 

Q: What does “conflict-free” mean?  

A: Conflict free means a case management agency will not provide both case management services and direct services to an individual, because this creates a conflict of interest.

CMS defines conflict-free case management as: “Providers of HCBS for the individual, or those who have an interest in or are employed by a provider of HCBS for the individual must not provide case management or develop the person-centered service plan, except when the State demonstrates that the only willing and qualified entity to provide case management and/or develop person-centered service plans in a geographic area also provides HCBS. In these cases, the State must devise conflict of interest protections including separation of entity and provider functions within provider entities, which must be approved by CMS.”

Q: Will there be exceptions to conflict-free case management?

A: Yes, HCPF will create a process for exceptions to conflict-free case management in areas where the approved case management agency is also the only willing and qualified provider in a defined service area to ensure access to services and supports statewide.

Q: How will CMRD benefit members?  

A: Currently, SEPs provide case management services for individuals on the following waivers: Brain Injury waiver, Community Mental Health Supports waiver, Elderly, Blind, and Disabled waiver, Complementary and Integrated Health waiver, Children’s Home and Community Services waiver, and Children with Life-Limiting Illness waiver. The CCBs provide case management services to members who have intellectual or developmental disabilities (IDD) on the following waivers: Developmental Disabilities waiver, Supported Living Services waiver, Children’s Extensive Support waiver, and Children’s Habilitation Residential Program waiver. Private Case Management agencies provide case management services to people on the Children’s Home and Community Based Services waiver.

Individuals seeking or receiving long-term services and supports often qualify for multiple programs and end up navigating systems that are siloed by the program. Case Management Redesign will create a simplified system where there is one place to go in each defined service area for case management for all waivers. Case Management Redesign will create consistency in the quality, accountability, and stability of the case management services people receive across the state. It will allow HCPF to provide oversight and support to ensure high performing case management system statewide.  

Q: Will members still have a choice of agency?  

A: Members will receive case management services from the agency that holds the contract in their defined service area. Case Management Agencies will have a process for members to request a new case manager if they are not a good fit.

Exceptions will be made if a person moves across defined service area boundaries and wants to continue being served by their previous agency. The process for this portability allowance and exception is still being formulated and will likely differ by defined service area. (Updated 8/25/22)

Q: What if I want to keep being served by my current agency but they don’t get awarded the contract?  

A: In the event there is a transition, HCPF works closely with both incoming and outgoing agencies to ensure there is very minimal impact on members. In our experience,  the majority of staff transition to the new agency, and individuals are able to retain their case manager if they so choose. 

Q: What will the impact be if a person moves from being served by a SEP or CCB to being served by a case management agency?   

A: The impact on members should be minimal if a transition does occur in your area. Most of the transition process will be business processes, contracts, materials, and files which are done “behind the scenes.” HCPF works with both incoming and outgoing agencies to ensure a smooth transition for members. Members can expect to experience outreach and communication regarding a change in their case management agency from both HCPF and the awarded case management agency.

During previous transitions between agencies, case management staff experience and expertise are highly valued and new agencies seek to retain case managers whenever possible. Unless case managers choose to leave, members can expect to continue with their current case manager through transitions whenever that is possible.

 
Q: How are defined service areas decided?  

A: HCPF hired a contractor to analyze data, caseloads, the numbers of assessments and support plans, and to look at geographical issues resulting in defined service area recommendations.  

Stakeholders provided feedback on the proposed maps and the contractor adjusted recommendations to HCPF based on webinar feedback and survey responses.  

Final defined service areas (the areas that the new case management agencies will service) were decided based on feedback in November 2021.

View Informational Memo IM 21-055 - CMRD Policy Update: Catchment Areas - November 2021

Q: Will contracts for Case Management go to the lowest bidder through the RFP process?

A: No. The rates for case management are set for all administrative and targeted activities. The RFP process will not evaluate costs but will evaluate best fit to serve the specific defined service area each agency applies for.

Q: How will CMRD impact Children’s-Home and Community Based Services (CHCBS)?

A: CHCBS members will continue to receive In-Home Support Services (IHSS) and case management services. HCPF will align CHCBS case management with the other waiver case management to meet efforts to simplify and streamline the current siloed system.  All case management agencies will be required to evolve with the changes required in Colorado's system, but HCPF is working closely with CMAs to support the retention of staff into the future case management system. (Updated 8/25/22)

Q: How will CMRD impact CCBs and mill levy?

A: The definition of CCBs will be amended but will ensure the continuity of local mill levy dollars as it pertains to HCBS recipients to be shared with local CMAs. HCPF, CCBs and CMAs will ensure that case managers are informed, educated and trained on all resources available to HCBS individuals in their defined service areas.

Q: How will CMRD impact providers or available services for members?

A: Providers will continue providing the same direct services per rules and regulations. Providers will be notified of any changes in case management agency in each defined service area via provider bulletin, HCPF communications, and communication from local case management agencies.

Q: What is HCPF doing to ensure stability among case managers at current CCBs and SEPs?

A: HCPF is aware of the uncertainty and anxiety that can be created with this level of change. HCPF leadership meets with CCB and SEP leadership groups on a monthly basis to discuss ways to support agencies and their staff through this transition. HCPF has approval to utilize American Rescue Plan Act (ARPA) funds to identify strategies to address these important concerns in our case management system. This work will be ongoing between now and July 2024. Check out the ARPA website for more information about this project! (Updated 8/25/22)

Q: I want to participate in upcoming stakeholder engagement efforts for Case Management Redesign. How do I get involved?

A: We are so glad you want to get involved! Please sign up for our twice weekly OCL Email Newsletter and our ARPA Project Pulse Newsletter to keep informed of opportunities! You can also Email John Barry for more information.

As a first step toward achieving the goals of Case Management Redesign, HCPF partnered with HCBS Strategies and Single Entry Point agencies (SEPs), Community Centered Boards (CCBs), and other stakeholders to design the plan for implementing the Case Management Redesign (CMRD) initiative in Colorado.

HCPF recognized the importance of ensuring stakeholders help shape the Case Management Redesign process, and hosted a kickoff meeting, smaller targeted focus group meetings, and a statewide stakeholder meeting.  All materials were posted on this page.

In addition, HCPF sent multiple surveys to all interested stakeholders to obtain feedback on the topic areas listed below.

Based on this work, HCPF identified decisions on the following topics for the future of Case Management Redesign: 

Defined Service Area - Initial plan for proposed defined service area maps for the consolidated SEP and CCB regions and rationale for the proposed approach. View Informational Memo IM 21-055 - CMRD Policy Update: Catchment Areas - November 2021 (Catchment area refers to what is now named defined service area)

Only Willing and Qualified Provider Exception - Identify provider capacity within the proposed defined service areas and where only willing and qualified provider exceptions may need to be made.

Organized Health Care Delivery System (OHCDS) - Discuss results of our research and interviews with other states around OHCDS.

Request for Proposal (RFP) Anti-Trust Laws and Bid Rigging Fact Sheet - December 2022